HCPCS - DME, Drugs, and Services
NEWS:
CMS says Less Paperwork for DME Suppliers after Jan 2023! 2022-08-18
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Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount. The fee schedule classifies most DMEPOS into one of six categories explained below:
For some basic information to get you started including modifiers and how CMS views DMEPOS, CLICK HERE |
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Dec 27th, 2022
Compliance Billing: Power Mobility Devices
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
In May of 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and assisting you in ensuring compliance.
Aug 18th, 2022
CMS says Less Paperwork for DME Suppliers after Jan 2023!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.
by CMS - MLNConnects
News - COVID-19: New Administration Code for Pfizer Pediatric Vaccine Booster Dose - - Biosimilars: Interchangeable Products May Increase Patient Access - - Critical Care Evaluation & Management Services: Comparative Billing Report in May - -...
May 2nd, 2022
Continuous Glucose Monitors (CGMs) -- New Codes
by Wyn Staheli, Director of Content - innoviHealth
New codes for continuous glucose monitors (CGMs) became effective on April 1, 2022. The following information is excerpted from MLN Matters MM12564 regarding CGMs. Be sure to review this information and implement policies to ensure accurate reporting/billing.
On December 28, 2021, we published the Medicare DMEPOS final rule in the Federal Register. This addressed the ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare made changes to the rules governing concurrently reporting transitional care management services and chronic care management services during the same calendar month. How might this help providers identify chronic conditions that risk adjust?
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...
Jun 29th, 2020
HCPCS Codes Were NOT all Created for the Same Purpose
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Have you ever wondered why you were unable to find a particular product/code with our DMEPOS search? When looking for HCPCS Level II codes, there are several kinds of codes and not all HCPCS codes were created for the same purpose. If you are searching for a certain HCPCS product ...
Aug 13th, 2019
Healthcare Common Procedure Coding System (HCPCS)
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
Jul 9th, 2019
When Can You Bill Orthosis Components Separately?
by Wyn Staheli, Director of Content - innoviHealth
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
Jan 22nd, 2019
Home Oxygen Therapy
by Raquel Shumway
Home Oxygen Therapy Guidelines
Oct 26th, 2018
Capped Rental Items
by Kristy Ritchie
CMS Gives guidance on Capped Rental Items:
Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months.
Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ...
Jun 14th, 2018
Home Oxygen Therapy -- CMN for Oxygen
by Raquel Shumway
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
May 9th, 2018
Preventive Medicine: Breastfeeding Supplies
by Find-A-Code™
Preventive Medicine Topics Page
Breastfeeding Supplies
Procedure Codes A4286: Locking ring for breast pump, replacement E0602: Breast pump, manual, any type E0603: Breast pump, electric (ac and/or dc), any type E0604: Breast pump, hospital grade, electric (ac and / or dc), any type S9443: Lactation classes, non-physician provider, per session
ICD-10-CM ...
Apr 19th, 2018
Coverage Criteria for Nonwearable Automatic Defibrillators
by Find-A-Code™
According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
The beneficiary has one of the following conditions (1-8):A documented episode of cardiac arrest due to ventricular fibrillation, not due to a ...
Mar 27th, 2018
Home Oxygen Therapy -- A Face-to-Face Encounter
by Raquel Shumway
What is required for a Home Oxygen Therapy, Face-to-Face Encounter.
Dec 28th, 2017
DME Documentation Requirements
by Wyn Staheli, Director of Content - innoviHealth
Properly documenting DME orders is crucial for reimbursement. It should be noted that without meeting the payer requirements, the claim will be denied. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. Commercial payers have similar policies so carefully ...
Oct 31st, 2017
Modifier NU
by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC
Is it necessary to use the modifier NU for all supplies? or is NU part of the code itself? Where should the NU be noted on the 1500 form?
by Jared Staheli, MPP
In order to bill drugs to the DME MACs, the supplier must be a pharmacy. States may not regulate the qualifications of Federal employees who are carrying out their authorized Federal activities within the scope of their employment. However, IHS employees are not subject to state licensure laws and IHS ...
by Jared Staheli, MPP
To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a “DME Supplier”, secure a Medicare supplier billing number and comply with the supplier standards specified in 42 CFR §424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction ...
Jun 18th, 2015
Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)
by Jared Staheli, MPP
Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.hhs.gov/providers/pufdownload/default.asp
The DMEPOS fee schedule applies to claims to FIs as follows.
BILL TYPE/ DEFINITION
ORTHOTICS/ PROSTHETICS
DME/ OXYGEN
12X (Hospital inpatient Part B)
Subject to fee schedule
Not covered, therefore, ...
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by Find-A-Code™
Proper Coding and Billing for Drugs, Biologicals and InjectionsLinks and resources by topic.
Billing
Coding
Compliance
DME
Documentation
Fees
HCPCS Coding
Medicare
OIG
Practice Management
Reimbursement
Medicare Resources
- February 12, 2015 - "DMEPOS Quality Standards" Booklet - Reminder - Released - The "DMEPOS Quality Standards" Booklet (ICN 905709) is available in downloadable format. This booklet is designed to provide education on Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). It includes DMEPOS quality standards as well as information on Medicare deemed Accreditation Organizations (AOs) for DMEPOS suppliers.
- February 12, 2015 - "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies" Fact Sheet - Reminder - Released - The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies" Fact Sheet (ICN 905711) is available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS-approved independent national Accreditation Organization (AO) as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
- Power Mobility Devices (PMDs): Complying with Documentation [PDF, 1MB] - This Fact Sheet (ICN 905063) is designed to provide education on Medicare coverage and billing requirements for PMDs. It includes information concerning basic coverage criteria and documentation requirements as well as, detailed coverage guidelines for the specific type of PMD provided.
- SE1112 Power Mobility Device Face-to-Face Examination Checklist [PDF, 100KB]
- Aug 15, 2014 - "DMEPOS Quality Standards" Booklet - Revised
The "DMEPOS Quality Standards" Booklet (ICN 905709) was revised and is now available in downloadable format. This booklet is designed to provide education on durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). It includes DMEPOS quality standards as well as information on Medicare deemed Accreditation Organizations for DMEPOS suppliers. - Aug 15, 2014 - "The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet - Revised
The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet (ICN 905711) was revised and is now available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS – approved independent national Accreditation Organization, as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements. - February 2014 - The Basics of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Accreditation [PDF, 757KB] - This fact sheet is designed to provide education on durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). It includes information so suppliers can meet DMEPOS Quality Standards established by the Centers for Medicare & Medicaid Services (CMS) and become accredited by a CMS-approved independent national Accreditation Organization (AO). There is also information on the types of providers who are exempt.
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