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Medicare 2016 Fee Schedule Changes for DME Industry

June 13, 2016



Medicare 2016 Fee Schedule Changes for DME Industry

Fees are updated every year based on the consumer price index and prevailing inflation. As per the act passed by legislation, the national limits are determined and set at a specific percentage of the median of all local fee amounts applicable for each laboratory test code.

Medical billing companies should note that copayments as well as deductibles are not applicable for services paid according to the Medicare clinical laboratory fee schedule. New laboratory test codes may be added year upon year to the laboratory fee schedule and the medical billing and coding companies need to keep their staff updated. Especially for Pap smear (cervical cancer) and vaginal smear tests the fee needs to always be higher than national minimum payment amount, which was earlier set at $14.60 and subject to updates each year in accordance with inflation.

Critical access hospitals are entitled to be paid for all outpatient laboratory tests in relation to the cost basis rather than by the fee schedule. All 50-bedded hospitals and those with fewer than 50 beds in designated rural areas are all paid on reasonable cost basis for all outpatient clinical laboratory tests.

For durable medical equipment, Medicare has proposals regarding the 3-year minimum lifetime requirement (MLR) for all routinely purchased DME items, which durable medical equipment billing services provider should note. The proposal also envisages budget-neutral fee schedules for splints and casts, as well as intraocular lenses (IOLs) fixed in the office of a physician.

The good news for durable medical equipment (DME) users who may be in need of prosthetics and orthotics (P & O), surgical dressings, therapeutic shoes, parental and enteral nutrition, and inserts shall be equal to 80 percent of the actual charges of the item or as per the fee schedule, whichever is lower, though unmet deductibles will not be included. Durable medical equipment companies should remember that it is the responsibility of the beneficiary to bear the remaining 20 percent of the actual charges, again whichever is lower of the fee schedule and actual charge of the item.

For Misvalued codes for 2016, the Achieving a Better Life Experience (ABLE) Act of 2014 set a 1% target for adjustments. Medical billing companies need to note that the payments under the fee schedule need to be reduced according to the difference between target set for the year and the amount by which the expenditures get reduced. For 2016, the net reduction in expenditures works out to 0.23 percent based on the adjustments made to misvalued codes.

According to the Medicare Physician Fee Schedule (MPFS) 2015 final rule all 10-day and 90-day global codes have transitioned to 0-day codes, medical billing companies need to be aware of this as well as the fact that MACRA prohibited CMS from implementing this policy, alternatively CMS has been instructed to develop a system to collect the requisite information to value surgical services from sample collected from physicians. The data collection process should commence not later than January 1, 2017. The information also needs to include the number of medical visits along with the respective levels during the global period.

 

Category : Best Billing and Coding Practices