(Medicare Claims Processing Manual)

Sort Sequence:  Category, HCPCS, 1st Modifier, 2nd Modifier State  Field Name  Pic Position  Comment  Year  X(4)  1 - 4 Applicable Update Year  HCPCS Code  X(5)  5 - 9 All current year active and deleted codes subject to DMEPOS floors and ceilings  1st Modifier  X(2)  10 - 11  2nd Modifier  X(2)  12 - 13  Jurisdiction  X 14 D = DME MAC Jurisdiction  L = Local A/B MAC (B) jurisdiction  J = Joint DME MAC/A/B MAC (B) jurisdiction  Category  X(2)  15 - 16 IN = Inexpensive/Routinely Purchased  FS = Frequently Serviced CR = Capped Rental  OX = Oxygen & Oxygen Equipment  OS = Ostomy, Tracheostomy & Urologicals  SD = Surgical Dressings  PO = Prosthetics & Orthotics  SU = Supplies  TE = TENS  TS = Therapeutic Shoes  SC = Splints and Casts  IL = Intraocular Lenses  HCPCS Action  X 17 Indicates active/delete status in HCPCS file  A = Active Code  D = Deleted Code, price provided for grace period processing only  Region  X(2)  18 - 19 This amount is not used for pricing claims.  It is on file for informational purposes.  00 = For all non Prosthetic and Orthotic Services  01 - 10 = For Prosthetic and Orthotic Services only.  This field denotes the applicable regional fee schedule.  State  X(2)  20 - 21  Original Base Fee  9(5)V99  22 - 28 This amount is not used for pricing claims.  It is on file for informational purposes.  For capped rental services, this amount represents the base fee after adjustments for rebasing and statewide conversions.  The base year for E0607 and L8603 is 1995.  S ince pricing amounts for E1405 and E1406 are developed by summing pricing amounts from source codes, they do not have a true base fee.  For these codes, this field will be filled with zeros.  Beginning January 1, 2016, this field will include the Competitive Bidding Rural Fee Amount for specific HCPCS codes.  A new indicator field (RURAL FEE INDICATOR) shall be populated with a value of R when the Rural Fee is present in this field.  Ceiling  9(5)V99  29 - 35 This amount is not used for pricing claims.  It is on file for informational purposes and could be integrated into other processes (i.e., IR review, validation, inquiries).  NOTE :  Since E0607 is priced via national IR, it is not priced using floors and ceilings.  For E0607, this field will be filled with zeros.  Since pricing amounts for E1405 and E1406 are developed by summing pricing amounts from source codes, they are not subject to ceilings and floors.  Since non- mail order (no -KL) codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259 are priced using National Mail order single payment amounts, they are not subject to ceilings and floors.  Splints, casts and intraocular lenses are national fee schedule amounts not subject to ceilings.  For these codes, this field will be filled with zeros. Beginning January 1, 2016, this field will also be filled with zeros for codes whose fees are adjusted using DMEPOS competitive bid information.  Floor  9(5)V99  36 - 42 This amount is not used for pricing claims.  It is on file for informational purposes and could be integrated into other processes (i.e., IR review, validation, inquiries).  NOTE :  Since E0607 is priced via national IR, it is not priced using floors and ceilings.  For E0607, this field will be filled with zeros.  Since pricing amounts for E1405 and E1406 are developed by summing pricing amounts from source codes, they are not subject to ceilings and floors.  Since non- mail order (no -KL) codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259 are priced using National Mail order single payment amounts, they are not subject to ceilings and floors.  Splints, casts and intraocular lenses are national fee schedule amounts not subject to floors.  For thes e codes, this field will be filled with zeros. Beginning January 1, 2016, this field will also be filled with zeros for codes whose fees are adjusted using DMEPOS competitive bid information.  Updated Fee Schedule Amount  9(5)V99  43 - 49 Amount used for pricing.  Filler  X 50 Set to spaces  Pricing Change Indicator  X 51 0 = No change to the updated fee schedule amount since previous release.  1 = A change has occurred to the updated fee schedule amount since the previous release.  Rural Fee Indicator  X(01)   R = Rural Fee is present in the Original Base Fee field Filler  X(8)  53 - 60 Set to spaces   60.2 - Quarterly Update Schedule for DMEPOS Fee Schedule  (Rev. 2902, Issued: 03- 11-14, Effective: 04 -01-14, Implementation: 04- 07-14)  Following is an approximate schedule for making additions (for new HCPCS codes) and corrections to base -year amounts for the DMEPOS fee schedule.    The DME MACs identify instances where base year fees are incorrect and forward requests for revisions to their regional offices.  The DME MACs also identify those instances where fee schedule amounts are replaced by inherent reasonableness (IR) limits/payment amounts, should the authority for making IR adjustments be restored.  A/B MACs (B) and DME MACs must use the file layout in 60.1  above to submit all revisions.  Regional offices will review those requests and, upon concurrence, forward them to the Division of Data Systems (DDS) and the Division of DMEPOS Policy (DDP) in CMS Central Office.  Those transmissions must occur within the timeframes established by CMS.    Requests for revisions must be accompanied by a narrative description.     For inherent reasonableness (IR) changes, the effective date of the revised payment amount must be provided.  The format provides a field for those dates.    DDS will recalculate the current year fee schedule amounts as appropriate.    DDS will transmit the entire DMEPOS file to the DME MACs, PDAC, and A/B MACs using the file layout described in 60.1 above.  An indicator in the record field will identify those instances where pricing amounts have changed.  These transmissions must occur within the dates specified each year by CMS.  DDP must also receive a copy of the corrected fees.    Concurrently, DDP issues instructions for implementing the revised fee schedule amounts.   DME MACs and A/B MACs should give providers 30 days notice before revised payment amounts are implemented.  Dates for implementation are provided by CMS.    DME MACs and A/B MACs should make adjustments on those claims that were processed incorrectly if brought to their attention.  Adjustments may be made retroactively to January 1 unless otherwise specified.   CMS will furnish the revised payment amounts to RRB, Indian Health Service and United Mine Workers.  DME MACs and A/B MACs (A), (B), and (HHH), shall provide the data to the State Medicaid Agencies.    Fee Schedule Disclaimer: Whenever the MACs publish the DMEPOS fee schedule in their bulletins/notices, a disclaimer must be added.  The disclaimer is, Inclusion or exclusion of a fee schedule amount for an item or service does not imply any health insurance coverage.    CMS will release specific timeframes for quarterly changes for DMEPOS Fees.   60.3 - Gap-filling DMEPOS Fees  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)  Gap-filling is used in establishing fee schedule amounts for new DMEPOS items or services that do not have a fee schedule pricing history. If a HCPCS code is new and describes items and services that have a fee schedule pricing history (classified and paid  for previously under a different code, including codes for miscellaneous items, e.g., E1399, and including fee schedule amounts established by CMS or the MACs), the fee schedule amounts for the new code are established using the process included in section 60.3.1 of this manual.   All DMEPOS items and services subject to payment on a fee schedule basis as mandated by sections 1833(o)(2)(A), 1834(a), (h), and (i) of the Social Security and/or by regulations at 42 CFR 414.102 and 414.210 must have national fee schedule amounts establi shed by CMS or interim local fee schedule amounts established by the MACs for use in paying claims for the items and services. Effective February 28, 2022, interim local fee schedule amounts established by the MACs for paying claims on an interim basis are  considered a fee schedule pricing history for continuity of pricing purposes under 60.3.1 below for the time before national fee schedule amounts are established, but can be considered by CMS in developing national fee schedule amounts. Once national fee  schedule amounts are established for an item or service, the national fee schedule amounts become the new fee schedule pricing history for the item or service for continuity of pricing purposes under 60.3.1 below.  Local fee schedule amounts established by the MACs for use in paying claims prior to February 28, 2022 are considered a fee schedule pricing history for continuity of pricing purposes under 60.3.1 below.  The DME MACs or A/B MACs must establish fee schedule amounts for DMEPOS items and services billed using HCPCS codes for miscellaneous items not otherwise classified under the HCPCS (e.g., E1399, L2999, and L8699). Once the fee schedule amounts are establis hed for DMEPOS items and services billed using HCPCS codes for miscellaneous items, these fee schedule amounts would only change when update factors are applied, to correct an error in the calculation of the fee schedule amounts, or based on program instru ctions.  For DME items, the DME MACs must apply the DME payment method depending on the DME class the item falls under (e.g., the item would be paid on a capped rental basis if it is expensive, not customized, not oxygen and oxygen equipment, and does not require frequent and substantial servicing in order to avoid risk to the patient).  National fee schedule amounts established by CMS and interim local fee schedule amounts established by the DME MACs and A/B MACs Part B shall be gap- filled for items for which charge data were unavailable during the fee schedule data base year using the fee schedule amounts for comparable equipment. Fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history are established using existing fee schedule amounts for comparable items when items with existing fee schedu le amounts are determined to be comparable to the new items and services. A comparison can be based on, but not limited to the following components : physical, mechanical, electrical, function and intended use, and additional attributes and features. When examining whether an item is comparable to another item, the analysis can be based on the items as a whole, its subcomponents, or a combination of items.  A new product does not need to be comparable within each category, and there is no prioritizatio n to t he categories.    Examples of Attributes in Each Component Category   Physical: Aesthetics, Design, Customized vs. Standard, Material, Portable, Size, Temperature Range/Tolerance, Weight    Mechanical:  Automated vs. Manual, Brittleness, Ductility, Durability, Elasticity, Fatigue, Flexibility, Hardness, Load Capacity, Flow -Control, Permeability, Strength   Electrical:  Capacitance, Conductivity, Dielectric Constant, Frequency, Generator, Impedance, Piezo -electric, Power, Power Source, Resistance    Function and Intended Use:  Function, Intended Use    Additional Attributes and Features: Smart, Alarms, Constraints, Device Limitations, Disposable, Parts, Features, Invasive vs. Non- Invasive.