DME April Changes Released by CMS

DME April Changes Released by CMS

If you’re submitting Durable Medical Equipment (DME) medical codes for billing , you’ll want to know April changes to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and services in the schedule.

Diabetic DME Codes

The Centers for Medicare & Medicaid Services (CMS) are releasing the new file just in time for the new quarter, but they will not include any ZIP code changes, the agency announced.

There are changes that may affect your coding of  HCPCS Level II code K0903  For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified CAD model created from a digitized scan of the patient, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each. CMS said the fees for K0903 are set based on the fees for code A5513 ,because inserts carved from a digitized scan of the patient’s foot were determined to be comparable to inserts made over a positive model of the patient’s foot.

DME Reflects Modifier Changes

Previously announced oxygen changes will impact the DMEPOS fee schedule. CMS said modifier QF  Prescribed amount of oxygen is greater than 4 Liter Per Minute (LPM) and portable oxygen is prescribed was added to the DMEPOS fee schedule for use with both stationary and portable oxygen when the oxygen flow rate exceeds 4 liters per minute (LPM) and portable oxygen is prescribed.

Remember that Section 1834(a)(5)(C) and (D) of the Act requires that when an oxygen flow rate exceeds 4 LPM, the Medicare payment amount be the higher of:

  • 50 percent of the stationary payment amount (HCPCS Level II codes E0424, E0439, E1390, or E1391); or
  • The portable oxygen add-on amount (HCPCS Level II codes E0431, E0433, E0434, E1392 or K0738); and
  • Never both.

The stationary oxygen modifier QF fee schedule amounts represent 100 percent of the stationary oxygen fee schedule amount. The portable oxygen QF fee schedule amounts represent the higher of 1) 50 percent of the monthly stationary oxygen payment amount; or 2) The fee schedule amount for the portable oxygen add-on amount. The modifier is billed on both the stationary oxygen and portable oxygen code when the prescribed amount of oxygen is greater than 4 LPM, portable oxygen is prescribed and there is no difference in the prescribed flow rate for nighttime and daytime use.

Along with the changes to modifier QF, it is being joined by modifier QB in April. QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (LPM) and portable oxygen is prescribed should be used in conjunction with claims submitted for stationary oxygen (codes E0424, E0439, E1390, or E1391) and portable oxygen (codes E0431, E0433, E0434, E1392, or K0738) when the prescribed amount of oxygen for daytime and nighttime differ and the average of the two amounts is greater than 4 liters per minute (LPM) and portable oxygen is prescribed, CMS explains.

Note modifier QB is used in billing to denote when:

  • The average prescribed amount of oxygen is greater than 4 LPM;
  • Portable oxygen is prescribed; and
  • There is a difference in the prescribed flow rates for nighttime and for daytime use.

In these instances, regulations at 42 CFR 414.226(e)(3)(iii) require that an average of the varying nighttime and daytime flow rates is to be used in determining the volume adjustment. Modifier QB is used when the average of the nighttime and daytime flow rates exceed 4 LPM and portable oxygen is prescribed.

What is Macra

Section 1834(a)(5)(C) and (D) of the Act also applies to modifier QB. This section of the Act requires that, when the oxygen flow rate exceeds 4 LPM, the Medicare payment amount is to be:

  • The higher of 50 percent of the stationary payment amount (codes E0424, E0439, E1390, or E1391); or
  • The portable oxygen add-on amount (E0431, E0433, E0434, E1392 or K0738); and
  • Never both.

 

 

Brad Ericson

Brad Ericson

Director of Publishing at AAPC
Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 10 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

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About Has 328 Posts

Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 10 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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