evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Upon successful receipt of the updated file(s), MACs send notification of receipt via email to price_file_receipt@cms.hhs.gov stating the name of the file received and the entities for which they were received (e.g., MAC name and A/B MAC (A) or (HHH) number).   A separate DMEPOS Fee Schedule file is released to A/B MACs (A) and (HHH), Railroad Retirement Board (RRB) and RRBs Specialty MAC, Indian Health Service, and United Mine Workers.  This fee schedule is also available on the CMS site (http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS -Fee-Schedule.html ) for other interested parties like the State Medicaid agencies and managed care organizations.  The fee schedule for parenteral and enteral nutrition (PEN) is released to the PDAC and DME MACs in a separate file.  All annual updates to fee schedules are t o be implemented on January 1 for claims with dates of service on or after January 1.   Effective February 28, 2022, national fee schedule amounts for new DMEPOS items and services that are added to the DMEPOS or PEN fee schedule files are established by CMS using the process summarized below and outlined in the regulations at 42 CFR 414.114 and 414.240. As explained in more detail in 60.3 below, MACs shall establish interim local fee schedule amounts for use in paying claims for new items and services billed using codes for miscellaneous items and services and for use in paying claims on an interim basis until the national fee schedule amounts are established.
(Medicare Claims Processing Manual)
Process for Establishing National Fee Schedule Amounts  Effective February 28, 2022  If a preliminary determination is made by CMS that a new item or service without a fee schedule pricing history falls under a DMEPOS benefit category, CMS makes a preliminary payment determination for the item or service and posts the preliminary payment determination on the website www.CMS.gov approximately 2 weeks prior to a public meeting. After consideration of public consultation provided at the public meeting on the preliminary benefit category and payment determinations for the item or service, CMS p osts final determinations on the website www.CMS.gov and implements the benefit category determinations and payment determinations for items and services through program instructions. Some determinations may be deferred to future cycles of the public consultation process if more time is needed to develop preliminary or final benefit category and payment determinations. Benefit category determinations are made using the public meeting process described above for an item or service that is the subject of a request for a HCPCS code set modification. Benefit category determinations are also made using the public meeting process in cases where a manufacturer for a new item or service is not requesting a HCPCS code set modification for the item or service, but requests CMS to determine whether the item or service falls under a DMEPOS benefit category. Benefit category determina tions are also made using the public meeting process when CMS identifies a need to address whether an item or service falls under a DMEPOS benefit category.  60.1 - Record Layout for DMEPOS Fee Schedule  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)
(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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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
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 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.   If unable to identify comparable item(s), other sources of pricing data can be used to calculate the gap -filled fee schedule amount for the new item. These sources include using supplier or commercial price lists with prices in effect during the fee schedule data base year.  Data base year refers to the time period mandated by the statute and/or regulations from which Medicare allowed charge data is to be extracted in order to compute the fee schedule amounts for the various DMEPOS payment categories. For  example, the fee schedule base year for inexpensive or routinely purchased durable medical equipment is the 12 month period ending June 30, 1987. Supplier price lists include catalogues and other retail price lists (such as internet retail prices) that pr ovide information on commercial pricing for the item. Potential appropriate sources for such commercial pricing information can also include payments made by Medicare Advantage plans as well as verifiable information from supplier invoices and non- Medicare payer data. DME MACs and A/B MACs shall gap- fill based on current instructions released each year for implementing and updating the payment amounts.  If the only available price information is from a period other than the base period, apply the deflation factors that are included in the current year implementation instructions against current pricing in order to approximate the base year price for gap- filling purposes.   The deflation factors for gap -filling purposes are:
(Medicare Claims Processing Manual)
Year*  OX CR PO SD PE SC IL 1987  0.965  0.971  0.974  n/a n/a n/a n/a 1988  0.928  0.934  0.936  n/a n/a n/a n/a 1989  0.882  0.888  0.890  n/a n/a n/a n/a 1990  0.843  0.848  0.851  n/a n/a n/a n/a 1991  0.805  0.810  0.813  n/a n/a n/a n/a 1992  0.781  0.786  0.788  n/a n/a n/a n/a 1993  0.758  0.763  0.765  0.971  n/a n/a n/a 1994  0.740  0.745  0.747  0.947  n/a n/a n/a 1995  0.718  0.723  0.725  0.919  n/a n/a n/a 1996  0.699  0.703  0.705  0.895  0.973  n/a n/a 1997  0.683  0.687  0.689  0.875  0.951  n/a n/a 1998  0.672  0.676  0.678  0.860  0.936  n/a n/a 1999  0.659  0.663  0.665  0.844  0.918  n/a n/a 2000  0.635  0.639  0.641  0.813  0.885  n/a n/a 2001  0.615  0.619  0.621  0.788  0.857  n/a n/a 2002  0.609  0.613  0.614  0.779  0.848  n/a n/a 2003  0.596  0.600  0.602  0.763  0.830  n/a n/a 2004  0.577  0.581  0.582  0.739  0.804  n/a n/a 2005  0.563  0.567  0.568  0.721  0.784  n/a
(Medicare Claims Processing Manual)
0.577  0.581  0.582  0.739  0.804  n/a n/a 2005  0.563  0.567  0.568  0.721  0.784  n/a n/a 2006  0.540  0.543  0.545  0.691  0.752  n/a n/a 2007  0.525  0.529  0.530  0.673  0.732  n/a n/a 2008  0.500  0.504  0.505  0.641  0.697  n/a n/a 2009  0.508  0.511  0.512  0.650  0.707  n/a n/a 2010  0.502  0.506  0.507  0.643  0.700  n/a n/a 2011  0.485  0.488  0.490  0.621  0.676  n/a n/a 2012  0.477  0.480  0.482  0.611  0.665  n/a n/a 2013  0.469  0.472  0.473  0.600  0.653  n/a 0.983  2014  0.459  0.462  0.464  0.588  0.640  0.980  0.963  2015  0.459  0.462  0.463  0.588  0.639  0.978  0.962  2016  0.454  0.457  0.458  0.582  0.633  0.969  0.952  2017  0.447  0.450  0.451  0.572  0.623  0.953  0.937  2018  0.435  0.437  0.439  0.556  0.605  0.927  0.911  2019  0.427  0.430  0.431  0.547  0.595  0.912  0.896  2020  0.425  0.427  0.429  0.544  0.592  0.906  0.891  2021  0.403  0.406  0.407  0.516  0.561  0.859  0.845  2022  0.370  0.372  0.373  0.473  0.515
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2021  0.403  0.406  0.407  0.516  0.561  0.859  0.845  2022  0.370  0.372  0.373  0.473  0.515  0.788  0.775
(Medicare Claims Processing Manual)
* Year price in effect   Payment Category Key:  OX Oxygen & oxygen equipment  (DME)  CR Capped rental  (DME)  IN Inexpensive/routinely purchased (DME)   FS Frequently serviced  (DME) SU DME  supplies  PO Prosthetics  & orthotics   SD Surgical  dressings  OS Ostomy, tracheostomy, and urological  supplies   PE Parental and enteral  nutrition TS Therapeutic Shoes   SC Splints and Casts  IL Intraocular Lenses inserted in a physicians office   IN, FS, OS and SU category deflation  factors=PO  deflation  factors   After deflation, the result must be increased by 1.7 percent and by the cumulative covered item update to complete the gap -filling (e.g., an additional .6 percent for a 2002 DME fee).  Note that when gap -filling for capped rental items, it is necessary to first gap -fill the purchase price then compute the base period fee schedule at 10 percent of the base period purchase price.   For used equipment, establish fee schedule amounts at 75 percent of the fee schedule amount for new equipment.  If within 5 years of establishing fee schedule amounts using supplier or commercial prices, the supplier or commercial prices decrease by less than 15 percent, CMS can make a one -time adjustment to the fee schedule amounts using the new prices.  The new supplier or commercial prices would be used to establish the new fee schedule amounts in the same way that the older prices were used, including application of the deflation formula of this section.   60.3.1 - Payment Concerns While Updating Codes  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)
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60.3.1 - Payment Concerns While Updating Codes  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)  The following instructions apply in situations where the CMS CO does NOT provide pricing guidance related to implementation of fee schedule for DMEPOS items and services.  Because a HCPCS code is new does not necessarily mean that Medicare payment on a fee schedule basis has never been made for the item and service described by the new code. In accordance with regulations at 42 CFR 414.110 and 414.236, if a new HCPCS code is  added, CMS and/or MACs make efforts to determine whether the item and service has a fee schedule pricing history. If there is a fee schedule pricing history, the previous fee schedule amounts for the previous code(s) are mapped to the new code(s) to ensur e continuity of pricing. When the code for an item is divided into several codes for the components of that item, the total of the separate fee schedule amounts established for the components must not be higher than the fee schedule amount for the original item. When there is a si ngle code that describes two or more distinct complete items (for example, two different but related or similar items), and separate codes are subsequently established for each item, the fee schedule amounts that applied to the single code continue to appl y to each of the items described by the new codes. When the codes for the components of a single item are combined in a single global code, the fee schedule amounts for the new code are established by totaling the fee schedule amounts used for the components (that is, use the total of the fee schedule amounts for the components as the fee schedule amount for the global code). When the codes for several different items are combined into a single code, the fee schedule amounts for the new code are established  using the average (arithmetic mean), weighted by allowed services, of the fee schedule amounts for the formerly separate codes.  60.4 - Process for Submitting Revisions to DMEPOS Fee Schedule to CMS  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)