Internal HCPCS Coding Decisions Planned for 2016

Internal HCPCS Coding Decisions Planned for 2016

The Centers for Medicare & Medicaid Services is conducting a limited demonstration for a web-based notice and comment mechanism allowing public input on requests to discontinue Level II HCPCS codes. Below are two notices for code changes planned for 2016. Speak now, or forever hold your peace…

DME Codes

June 18, CMS released new internal HCPCS coding decisions regarding HCPCS Level II codes used for processing Medicare claims for miscellaneous durable medical equipment (DME).

HCPCS Level II codes E1399 Durable medical equipment, miscellaneous and K0108 Wheelchair component or accessory, not otherwise specified are both currently being used to bill for inexpensive DME. To allow for accurate payment of Medicare claims for DME items and replacement parts for DME items, CMS intends to replace E1399 and K0108 for six new codes that represent:

  1. a) inexpensive DME;
  2. b) other DME or expensive DME; and
  3. c) replacement parts for DME being repaired.

The following HCPCS Level II codes will be effective Jan. 1, 2016:

1)  KXXX1 Durable Medical Equipment, Miscellaneous, the Purchase Price Does Not Exceed $150

2)  KXXX2 Durable Medical Equipment, Miscellaneous, the Purchase Price Exceeds $150

3)  KXXX3 Wheelchair Component or Accessory, Miscellaneous, the Purchase Price Does not Exceed $150

4)  KXXX4 Wheelchair Component or Accessory, Miscellaneous, the Purchase Price Exceeds $150

5)  KXXX5 Repair Part For Use With Beneficiary Owned Durable Medical Equipment, Other Than Wheelchair, Not Covered Under Supplier Or Manufacturer Warranty, Not Otherwise Specified

6)  KXXX6 Repair Part For Use With Beneficiary Owned Wheelchair, Not Covered Under Supplier Or Manufacturer Warranty, Not Otherwise Specified

“In no case may a claim for a replacement part for repair of DME be billed using codes KXXX1 thru KXXX4,” CMS warns in the release.

Codes KXXX1 and KXXX3 are to be used if the supplier’s actual charge for purchase of the item is $150 or less, or for rental claims, if the supplier’s actual charge for rental of the item is $15 or less. If the supplier’s actual charge exceeds these thresholds, codes KXXX2 or KXXX4 should be used. Payment of covered items described by codes KXXX5 and KXXX6 will be made on a lump sum purchase basis in an amount that is based on the contractor’s individual consideration of the item.

Payment amounts for the new codes will be updated by the 2016 covered item update for use in paying claims with dates of service on or after January 1, 2016.

CMS is accepting electronic comments on this issue that are submitted on or before July 9, 2015. See the release for commenting instructions.

Ventilator Codes

Earlier this month, CMS released an internal decision regarding ventilator codes.

Effective Jan. 1, 2016, the following two HCPCS Level II codes (numbers not yet assigned) will be added:

EXXX1 Home ventilator, any type used with invasive interface (e.g., tracheostomy tube)

EXXX2 Home ventilator, any type, used with non-invasive interface (e.g., mask, chest shell)

CMS will discontinue the following codes, effective Dec. 31, 2015:

E0450 Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)

E0460  Negative pressure ventilator, portable or stationary

E0461  Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask)

E0463  Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)

E0464  Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)

New code EXXX1 will be used for ventilators currently described by codes E0450 and E0463, while new code EXXX2 will be used for ventilators currently described by codes E0460, E0461 and E0464.

According to CMS, these code changes are necessary because “Program abuse is occurring when code E0464 is used inappropriately to bill for pressure support ventilators that can also function as and are used as positive airway pressure devices for treatment of OSA rather than treatment of respiratory failure.”

The Medicare fee schedule amounts for code E0450 will be used to establish the fee schedule amounts for both EXXX1 and EXXX2.

CMS says it intends to closely monitor use of new codes EXXX1 and EXXX2 to ensure that items used for the treatment of OSA are not being billed under these codes.

Comments on these coding actions will be considered if received by 5 pm on June 25, 2015. See the release for commenting instructions.

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.
Renee Dustman

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Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.

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