The Centers for Medicare & Medicaid Services (CMS) updates the DMEPOS fee schedule on an annual basis in accordance with statutes and regulations. Payment on a fee schedule basis is required for certain Durable Medical Equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by Section1834 (a), (h), and (i) of the Social Security Act (the Act).
Additionally, payment on a fee schedule basis is a regulatory requirement at 42 Code of Federal Regulation (CFR) Section 414.102 for Parenteral and Enteral Nutrition (PEN), splints, casts, and Intraocular Lenses (IOLs) inserted in a physician’s office.
The DMEPOS and PEN fee schedule files contain Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the adjusted fee schedule amounts under Section 1834(a)(1)(F) as well as codes that are not subject to the fee schedule Competitive Bidding Program (CBP) adjustments.
New Codes Added
New DMEPOS codes added to the HCPCS file, effective January 1, 2019, where applicable, are A4563, A5514, A6460, A6461, B4105, E0447, E0467, L8608, L8698, L8701, L8702, V5171, V5172, V5181, V5211, V5212, V5213, V5214, V5215, and V5221. The new codes are not to be used for billing purposes until they are effective on January 1, 2019.
As part of this update, fee schedules for the following new codes will be added to the DMEPOS fee schedule file effective January 1, 2019: A4563, A5514, E0447, and E0467. Beginning January 1, 2019, the DMEPOS fee schedule file also includes fees for G0068, G0069, and G0070 three home infusion G-codes.
For other new CY 2019 codes, fee schedule amounts will be established as part of the July 2019 DMEPOS fee schedule update when applicable. The DME MAC shall establish local fee schedule amounts to pay claims for new codes listed from January 1, 2019, through June 30, 2019.
For gap-filling pricing purposes, deflation factors are applied before updating to the current year. The deflation factors for 2018 by payment category are:
- 435 for Oxygen
- 437 for Capped Rental
- 439 for Prosthetics and Orthotics
- 556 for Surgical Dressings
- 605 for Parental and Enteral Nutrition
- 927 for Splints and Casts
- 911 for Intraocular Lenses
One HCPCS code (K0903) will be deleted from the DMEPOS fee schedule files effective January 1, 2019
Effective January 1, 2019, fees are added for new HCPCS code E0467 (Home ventilator, multifunction respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components, and supplies for all functions). Pursuant to 42 CFR 414.222(f), the fee schedule amounts for code E0467 are established using the Medicare fee schedule amounts for ventilators and the average cost of the additional functions performed by multi-function ventilators.
The multi-function ventilator is classified under the frequent and substantial servicing payment category at Section 1834(a)(3) of the Act and payment will be made on a continuous monthly rental basis for beneficiaries who meet the Medicare medical necessity coverage criteria for a ventilator and at least one of the four additional functions of the device.
Therapeutic Shoe Modification Codes
CMS is also adjusting the fee schedule amounts for shoe modification codes A5503 through A5507 as part of this update in order to reflect more current allowed service data. Section 1833(o)(2)(C) of the Act required that the payment amounts for shoe modification codes A5503 through A5507 be established in a manner that prevented a net increase in expenditures when substituting these items for therapeutic shoe insert codes (A5512 or A5513).
To establish the fee schedule amounts for the shoe modification codes, the base fees for codes A5512 and A5513 were weighted based on the approximated total allowed services for each code for items furnished during the second quarter of CY 2004. For 2019, CMS is updating the weighted average insert fees used to establish the fee schedule amounts for the shoe modification codes with more current allowed service data for each insert code.
The base fees for A5512 and A5513 will be weighted based on the approximated total allowed services for each code for items furnished during the CY 2017. The fee schedule amounts for shoe modification codes A5503 through A5507 are revised to reflect this change, effective January 1, 2019.
Diabetic Testing Supplies
The fee schedule amounts for non-mail order Diabetic Testing Supplies (DTS) (without KL modifier) for codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259 are not updated by the annual covered item update. In accordance with Section 1834(a)(1)(H) of the Act, the fee schedule amounts for these codes were adjusted in CY 2013 so that they are equal to the SPAs for mail order DTS established in implementing the national mail-order CBP under Section 1847 of the Act.
For dates of service between January 1, 2019, and December 31, 2019, the National Mail-Order Recompete SPAs are updated by the projected change of 2.5%. The national mail-order adjusted fee schedule amounts will be used in paying mail-order diabetic testing supply claims in all parts of the United States.