Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 3716 Date: February 10, 2017

Transcription

1 CS anual System Pub edicare Claims Processing Department of Health & Human Services (DHHS) Centers for edicare & edicaid Services (CS) Transmittal 3716 Date: February 10, 2017 Change Request 9968 SUBJECT: Extension of the Transition to the Fully Adjusted Durable edical Equipment, Prosthetics, Orthotics and Supplies Payment Rates under Section of the 21st Century Cures Act I. SUARY OF CHANGES: This change request (CR) provides instructions regarding the implementation of revised 2016 Durable edical Equipment, Prosthetics, Orthotics and Supplies (DEPOS) fee schedule amounts based on changes mandated by section of the 21st Century Cures Act. EFFECTIVE DATE: July 1, 2016 *Unless otherwise specified, the effective date is the date of service. IPLEENTATION DATE: July 3, 2017 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN AAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D R N CHAPTER / SECTION / SUBSECTION / TITLE Table of Contents 20/20/20.6/ Phase-In for Competitive Bidding Rates in Areas Not in a Competitive Bid Area III. FUNDING: For edicare Administrative Contractors (ACs): The edicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CS does not construe this as a change to the AC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by , and request formal directions regarding continued performance requirements. IV. ATTACHENTS: Business Requirements anual Instruction

2 Attachment - Business Requirements Pub Transmittal: 3716 Date: February 10, 2017 Change Request: 9968 SUBJECT: Extension of the Transition to the Fully Adjusted Durable edical Equipment, Prosthetics, Orthotics and Supplies Payment Rates under Section of the 21st Century Cures Act EFFECTIVE DATE: July 1, 2016 *Unless otherwise specified, the effective date is the date of service. IPLEENTATION DATE: July 3, 2017 I. GENERAL INFORATION A. Background: Legislation effective January 1, 2017, requires changes to the July and October 2016 fee schedule amounts for certain items. This change request (CR) provides instructions regarding the implementation of revised 2016 Durable edical Equipment, Prosthetics, Orthotics and Supplies (DEPOS) fee schedule amounts based on changes mandated by section of the 21st Century Cures Act. Section 1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for certain DE items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs for DE. Regulations at section (g)(9) phased in these adjusted fees so that from January 1, 2016 through June 30, 2016, the fee schedule amount in non-bid areas was based on 50 percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount (i.e., the 2015 fee schedule amount updated by the 2016 covered item update). Beginning July 1, 2016, the fee schedule amounts for non-bid areas reverted to 100 percent of the adjusted payment amounts determined using competitive bidding information. B. Policy: Section of the 21st Century Cures Act changes the 2016 fee schedule transition period so that payment based on 50 percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount extends from June 30, 2016 to December 31, Section also changes from July 1, 2016 to January 1, 2017 the date that payment based on 100 percent of the adjusted payment amounts in non-bid areas is effective. To implement section for dates of service July 1, 2016 through December 31, 2016, the 50/50 blend fee schedules have been recalculated so that the adjusted portion of the payment blend utilizes July 1, 2016 adjusted fees. Also, the KE modifier fee schedules for items bid in the initial Round 1 Competitive Bidding Program have been added back to the fee schedule file for this extended phase-in period. The KE modifier was added to the DEPOS fee schedule file as part of the January 2009 fee schedule update and described items that were bid under the initial Round 1 Competitive Bidding Program but were used with noncompetitive bid base equipment. Suppliers should submit a request for reopening if their claim for dates of service between July 1, 2016 and December 31, 2016 should have been processed with the KE modifier. The revised July 1, 2016 through December 31, 2016 DEPOS and PEN fee schedule files will be made available to contractors as part of this change request. The previously posted July 2016 and October 2016 DEPOS and PEN public use files will be revised to reflect the new fee schedule amounts associated with the extension of the transition period. The contractor shall accept the KE modifier on the adjusted claims. In addition, for claims that the KE modifier would have been applicable to, the supplier may adjust the claim or notify the ACs to adjust the claims after the mass adjustments for the 50/50 fee blend have been completed.

3 II. BUSINESS REQUIREENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B AC D E Shared- System aintainers The DE ACs and/or VDCs shall retrieve the revised July 2016 DEPOS fee schedule file (filename: U00.@BF12393.DEPOS.T V07). The revised file is available for download on or after ay 01, A B H H H A C F I S S C S V S C W F VDC Other The DE ACs and/or VDCs shall retrieve the revised October 2016 DEPOS fee schedule file (filename: U00.@BF12393.DEPOS.T V10). The revised file is available for download on or after ay 01, Notification of successful receipt of both July and October 2016 revised files shall be sent via to price_file_receipt@cms.hhs.gov stating the name of the file received and the entity receiving the file (e.g., contractor name and number). VDC VDC The HHH ACs and/or VDCs shall retrieve the revised July 2016 DEPOS fee schedule file (filename: U00.@BF12393.DEPOS.T V07.FI). The revised file is available for download on or after ay 01, The HHH ACs and/or VDCs shall retrieve the revised October 2016 DEPOS fee schedule file (filename: U00.@BF12393.DEPOS.T V10.FI). The revised file is available for download on or after ay 01, Notification of successful receipt of both July and October 2016 revised files shall be sent via to price_file_receipt@cms.hhs.gov stating the name of the file received and the entity receiving the file (e.g., contractor name and number). VDC VDC VDC

4 Number Requirement Responsibility A/B AC D E Shared- System aintainers The DE ACs and/or VDCs shall retrieve the revised July 2016 PEN fee schedule file (filename: U00.@BF12393.PEN.CY16.V07). The revised file is available for download on or after ay 01, A B H H H A C F I S S C S V S C W F VDC Other The DE ACs and/or VDCs shall retrieve the revised October 2016 PEN fee schedule file (filename: U00.@BF12393.PEN.CY16.V10). The revised file is available for download on or after ay 01, Notification of successful receipt of both July and October 2016 revised files shall be sent via to price_file_receipt@cms.hhs.gov stating the name of the file received and the entity receiving the file (e.g., contractor name and number). VDC VDC Contractors shall create a one-time process to validate and adjust claims using the new 2016 DEPOS fee schedule file when the following is true: dates of service July 1, 2016 through December 31, 2016, a HCPCS/odifier combination found on the list in Attachment A; and the beneficiary did NOT reside in a Round 1 (2014) or Round 2 (2016) Competitive Bidding Area; OR the beneficiary resided in a Round 1 (2014) or Round 2 (2016) Competitive Bidding Area, but the item was grandfathered and paid at the fee schedule price (Attachment B); OR The beneficiary resided in a Round 1 (2014) or Round 2 (2016) Competitive Bidding Area, but the item was associated with the KY modifier and paid at the fee schedule price

5 Number Requirement Responsibility A/B AC D E Shared- System aintainers Contractors shall reprocess affected claims from the date that the revised fee schedule files have been loaded or from the date that the SS alerts the AC region/workload that its claims have been adjusted, whichever is later. A B H H H A C F I S S C S V S C W F Other Contractors shall adjust claims that were previously paid Contractors shall begin the one-time claim adjustment process once the revised fee schedule files are available within the DE production regions rather than wait until the implementation date of this CR After the claim has been adjusted via the systematic process to reprice using the revised fee schedule prices, the Contractors shall re-adjust claims, with dates of service July 1, 2016 through December 31, 2016, submitted with the KE modifier when brought to their attention The contractor shall create a process to re-load the following DEPOS fee schedule file: July 2016, and October 2016 III. PROVIDER EDUCATION TABLE Number Requirement Responsibility LN Article: A provider education article related to this instruction will be available at Network-LN/LNattersArticles/ shortly after the CR is released. You will receive notification of the article release via the established "LN atters" listserv. Contractors shall post this article, or a direct link to this article, on their Web sites and include information about it in a listserv message within 5 A/B AC A B H H H D E A C C E D I

6 Number Requirement Responsibility business days after receipt of the notification from CS announcing the availability of the article. In addition, the provider education article shall be included in the contractor's next regularly scheduled bulletin. Contractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. A/B AC A B H H H D E A C C E D I IV. SUPPORTING INFORATION Section A: Recommendations and supporting information associated with listed requirements: N/A "Should" denotes a recommendation. -Ref Requirement Number Recommendations or other supporting information: Section B: All other recommendations and supporting information: N/A V. CONTACTS Pre-Implementation Contact(s): Bobbett Plummer, or bobbett.plummer@cms.hhs.gov (For claims processing instructions), Karen Jacobs, or karen.jacobs@cms.hhs.gov (For policy questions) Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR). VI. FUNDING Section A: For edicare Administrative Contractors (ACs): The edicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CS does not construe this as a change to the AC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by , and request formal directions regarding continued performance requirements. ATTACHENTS: 1

7 edicare Claims Processing anual Chapter 20 Durable edical Equipment, Prosthetics, Orthotics, and Supplies (DEPOS) Transmittals for Chapter 20 Table of Contents (Rev.3716, Issued: ) 20.6 Phase-in For Competitive Bid Rates in Areas Not in a Competitive Bid Area

8 20.6 Phase-in For Competitive Bid Rates in Areas Not in a Competitive Bid Area (Rev. 3716, Issued: , Effective: , Implementation: ) Section 1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for certain DE items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs for DE. Regulations at section (g)(9) phased in these adjusted fees so that from January 1, 2016 through June 30, 2016, the fee schedule amount in non-bid areas was based on 50 percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount (i.e., the 2015 fee schedule amount updated by the 2016 covered item update). Beginning July 1, 2016, the fee schedule amounts for non-bid areas reverted to 100 percent of the adjusted payment amounts determined using competitive bidding information. Section of the 21st Century Cures Act changes the 2016 fee schedule transition period so that payment based on 50 percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount extends from June 30, 2016 to December 31, Section also changes from July 1, 2016 to January 1, 2017 the date that payment based on 100 percent of the adjusted payment amounts in non-bid areas is effective.

9 Attachment A HCPCS odifier 1 odifier 2 A4221 Attachment B Grandfathered Codes Paid at Fee Schedule HCPCS HCPCS Code Description Round CBA Commode chair with E0165 detacharm Round 1 A4222 A4557 A4595 A4604 E0170 E0171 E0181 E0182 Commode chair electric Round 1 Commode chair nonelectric Round 1 Press pad alternating w/ pum Round 1 Replace pump, alt press pad Round 1 A4619 A4636 E0186 E0187 Air pressure mattress Round 1 Water pressure mattress Round 1 A4636 A4636 E0193 E0196 Powered air flotation bed Round 1 Gel pressure mattress Round 1 A4637 A4637 A4637 E0197 E0277 E0371 Air pressure pad for mattres Round 1 Powered pres-redu air mattrs Round 1 Nonpower mattress overlay Round 1 A4640 A4640 A4640 E0372 E0373 E0565 Powered air mattress overlay Round 1 Nonpowere d pressure mattress Round 1 Compressor air power source Round 1

10 A6550 A7000 E0570 E0572 Nebulizer with compressio n Round 1 Aerosol compressor adjust pr Round 1 A7003 A7004 A7005 E0585 E0630 E0635 Nebulizer w/ compressor & he Round 1 Patient lift hydraulic Round 1 Patient lift electric Round 1 A7006 A7007 A7010 E0636 E0779 E0781 Pt support & positioning sys Round 1 Amb infusion pump mechanical Round 1 External ambulatory infus pu Round 1 A7012 A7013 A7014 E0784 E0791 E0958 Ext amb infusn pump insulin Round 1 Parenteral infusion pump sta Round 1 Whlchr attconv 1 arm drive Round 1 A7015 A7017 A7017 A7017 A7018 E0985 E1031 E1035 E1036 E1037 W/c seat lift mechanism Round 1 Rollabout chair with casters Round 1 Patient transfer system <300 Round 1 Patient transfer system >300 Round 1 Transport chair, ped size Round 1

11 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 E1038 E1039 E1225 E2228 E2402 K0001 K0002 K0003 K0004 K0006 K0007 K0070 K0195 E0165 Transport chair pt wt<=300lb Round 1 Transport chair pt wt >300lb Round 1 anual semireclining back Round 1 wc acc, wheelchair brake Round 1 Neg press wound therapy pump Round 1 Standard wheelchair Round 1 Stnd hemi (low seat) whlchr Round 1 Lightweight wheelchair Round 1 High strength ltwt whlchr Round 1 Heavy duty wheelchair Round 1 Extra heavy duty wheelchair Round 1 Rr whl compl pne tire rep ea Round 1 Elevating whlchair leg rests Round 1 Commode chair with detacharm Round 2 A7045 A7045 A7045 A7046 E0170 E0171 E0181 E0182 Commode chair electric Round 2 Commode chair nonelectric Round 2 Press pad alternating w/ pum Round 2 Replace pump, alt press pad Round 2

12 B4035 B4036 B4034 E0186 E0187 E0196 Air pressure mattress Round 2 Water pressure mattress Round 2 Gel pressure mattress Round 2 B4081 B4082 B4083 B4087 E0197 E0565 E0570 E0572 Air pressure pad for mattres Round 2 Compressor air power source Round 2 Nebulizer with compressio n Round 2 Aerosol compressor adjust pr Round 2 B4088 B4149 B4150 E0585 E0630 E0635 Nebulizer w/ compressor & he Round 2 Patient lift hydraulic Round 2 Patient lift electric Round 2 B4152 B4153 E0636 E0958 Pt support & positioning sys Round 2 Whlchr attconv 1 arm drive Round 2 B4154 B4155 B9000 B9000 S E0985 E1035 E1036 E1037 W/c seat lift mechanism Round 2 Patient transfer system <300 Round 2 Patient transfer system >300 Round 2 Transport chair, ped size Round 2

13 B9000 B9000 B9002 S E1039 E2228 E2375 Transport chair pt wt >300lb Round 2 wc acc, wheelchair brake Round 2 Nonexpandable controller Round 2 B9002 B9002 B9002 E0130 E0130 E0130 E0135 E0135 E0135 E0140 E0141 E0141 E0141 E0143 E0143 E0143 E0144 E0147 E0147 E0147 E0148 E0148 E0148 E0149 E0154 E0154 E0154 E0155 E0155 E0155 E0156 E0156 E0156 E0157 E0157 E0157 E2378 Pw actuator replacement Round 2

14 E0158 E0158 E0158 E0159 E0159 E0159 E0160 E0160 E0160 E0161 E0161 E0161 E0163 E0163 E0163 E0165 E0167 E0167 E0167 E0168 E0168 E0168 E0170 E0171 E0181 E0182 E0184 E0184 E0184 E0185 E0185 E0185 E0186 E0187 E0188 E0188 E0188 E0189 E0189 E0189 E0193 E0196 E0197 E0199 E0199 E0199 E0250

15 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0271 E0271 E0271 E0272 E0272 E0272 E0275 E0275 E0275 E0276 E0276 E0276 E0277 E0280 E0280 E0280 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0300 E0301 E0302 E0303 E0304 E0305 E0310 E0310 E0310 E0316 E0325 E0325 E0325 E0326 E0326 E0326

16 E0371 E0372 E0373 E0424 E0431 E0433 E0434 E0439 E0441 E0442 E0443 E0444 E0470 E0471 E0472 E0561 E0561 E0561 E0562 E0562 E0562 E0565 E0570 E0572 E0580 E0580 E0580 E0585 E0601 E0621 E0621 E0621 E0627 E0627 E0627 E0628 E0628 E0628 E0629 E0629 E0629 E0630 E0635 E0636 E0705 E0705 E0705

17 E0720 E0730 E0731 E0776 BA E0776 BA E0776 BA E0776 E0776 E0776 E0779 E0780 E0781 E0784 E0791 E0910 E0911 E0912 E0940 E0950 E0950 E0950 E0951 E0951 E0951 E0952 E0952 E0952 E0955 E0956 E0956 E0956 E0957 E0957 E0957 E0958 E0959 E0959 E0959 E0960 E0960 E0960 E0961 E0961 E0961 E0966 E0966 E0966

18 E0967 E0967 E0967 E0971 E0971 E0971 E0973 E0973 E0973 E0974 E0974 E0974 E0978 E0978 E0978 E0981 E0981 E0981 E0982 E0982 E0982 E0985 E0990 E0990 E0990 E0992 E0992 E0992 E0995 E0995 E0995 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1010 E1015 E1015 E1015 E1016 E1016 E1016 E1020 E1028

19 E1029 E1030 E1031 E1035 E1036 E1037 E1038 E1039 E1225 E1226 E1226 E1226 E1372 E1372 E1372 E1390 E1391 E1392 E2201 E2201 E2201 E2202 E2202 E2202 E2203 E2203 E2203 E2204 E2204 E2204 E2205 E2205 E2205 E2206 E2206 E2206 E2207 E2207 E2207 E2208 E2208 E2208 E2209 E2209 E2209 E2210 E2210

20 E2210 E2211 E2211 E2211 E2212 E2212 E2212 E2213 E2213 E2213 E2214 E2214 E2214 E2215 E2215 E2215 E2219 E2219 E2219 E2220 E2220 E2220 E2221 E2221 E2221 E2222 E2222 E2222 E2224 E2224 E2224 E2225 E2225 E2225 E2226 E2226 E2226 E2228 E2231 E2231 E2231 E2310 E2311 E2321 KC E2321 E2322 KC E2322

21 E2323 E2323 E2323 E2324 E2324 E2324 E2325 E2326 E2327 E2328 E2329 E2330 E2351 E2351 E2351 E2359 E2359 E2359 E2360 E2360 E2360 E2361 E2361 E2361 E2362 E2362 E2362 E2363 E2363 E2363 E2364 E2364 E2364 E2365 E2365 E2365 E2366 E2366 E2366 E2367 E2367 E2367 E2368 E2369 E2370 E2371 E2371

22 E2371 E2373 KC E2374 E2375 E2376 E2377 E2378 E2381 E2381 E2381 E2382 E2382 E2382 E2383 E2383 E2383 E2384 E2384 E2384 E2385 E2385 E2385 E2386 E2386 E2386 E2387 E2387 E2387 E2388 E2388 E2388 E2389 E2389 E2389 E2390 E2390 E2390 E2391 E2391 E2391 E2392 E2392 E2392 E2394 E2394 E2394 E2395

23 E2395 E2395 E2396 E2396 E2396 E2397 E2397 E2397 E2402 E2601 E2601 E2601 E2602 E2602 E2602 E2603 E2603 E2603 E2604 E2604 E2604 E2605 E2605 E2605 E2606 E2606 E2606 E2607 E2607 E2607 E2608 E2608 E2608 E2611 E2611 E2611 E2612 E2612 E2612 E2613 E2613 E2613 E2614 E2614 E2614 E2615 E2615

24 E2615 E2616 E2616 E2616 E2619 E2619 E2619 E2620 E2620 E2620 E2621 E2621 E2621 E2622 E2622 E2622 E2623 E2623 E2623 E2624 E2624 E2624 E2625 E2625 E2625 E2626 E2626 E2626 E2627 E2627 E2627 E2628 E2628 E2628 E2629 E2629 E2629 E2630 E2630 E2630 E2631 E2631 E2631 E2632 E2632 E2632 E2633

25 E2633 E2633 K0001 K0002 K0003 K0004 K0006 K0007 K0015 K0017 K0017 K0017 K0018 K0018 K0018 K0019 K0019 K0019 K0020 K0020 K0020 K0037 K0037 K0037 K0038 K0038 K0038 K0039 K0039 K0039 K0040 K0040 K0040 K0041 K0041 K0041 K0042 K0042 K0042 K0043 K0043 K0043 K0044 K0044 K0044 K0045 K0045

26 K0045 K0046 K0046 K0046 K0047 K0047 K0047 K0050 K0050 K0050 K0051 K0051 K0051 K0052 K0052 K0052 K0053 K0053 K0053 K0056 K0056 K0056 K0065 K0065 K0065 K0069 K0069 K0069 K0070 K0071 K0071 K0071 K0072 K0072 K0072 K0073 K0073 K0073 K0077 K0077 K0077 K0098 K0098 K0098 K0105 K0105 K0105

27 K0195 K0552 K0601 K0602 K0603 K0604 K0605 K0733 K0733 K0733 K0738 K0800 K0800 K0800 K0801 K0801 K0801 K0802 K0802 K0802 K0806 K0806 K0806 K0807 K0807 K0807 K0808 K0808 K0808 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0835 K0836 K0837 K0838

28 K0839 K0840 K0841 K0842 K0843