by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 15th, 2016
The Patient Access and Medicare Protection Act (PAMPA) was recently signed into law on December 28, 2015. Beginning January 1, 2016, the DME fee schedule rates are adjusted to reflect information from the DMEPOS competitive bidding program as required by section 1834(a)(1)(F)(ii) of the Social Security Act. These adjustments are being phased in during the initial 6 months of 2016 so that the fee schedule amounts in all areas will be based on a 50/50 blend of current rates and adjusted rates. Section 2 of PAMPA mandates that adjustments to the 2016 Medicare fee schedule amounts for certain durable medical equipment (DME) based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs. Group 3 complex rehabilitative power wheelchair bases are currently described by codes K0848 through K0864 of the Healthcare Common Procedure Coding System (HCPCS).
Although this change is effective January 1, 2016, changes to the Medicare claims processing systems cannot be implemented any sooner than July 1, 2016. Until these changes are implemented, payment for these items will be based on the adjusted fee schedule amounts. Suppliers can submit claims for these items with dates of service on or after January 1, 2016, but payment will be based on the adjusted fee schedule amounts. On or after July 1, 2016, suppliers can adjust previously paid claims with dates of service on or after January 1, 2016, to receive the full fee schedule amount. For these items, the average adjustments to the 2016 rates in the transition period is about a reduction of 10 percent.
Additional information, including a list of HCPCS codes for accessories affected by this change, as well as further instructions regarding the submission and processing of these claims, will be provided in the coming months. https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html
Because the changes to the Medicare claims processing system cannot be implemented any sooner than July 1, the Part B Medicare contractors are unable to process claims within established time limits and an advance payment may be available. Suppliers are able to submit a single advance payment request for multiple claims for an eligible period of time. Note an advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met.
To apply for an advance payment, the Medicare supplier is required to submit the request to their appropriate Medicare Administrative Contractor. CMS will not make advance payments in the case where a supplier is unable to submit a valid claim for services rendered.