LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2011-12 MLN Matters® Number: MM7638 Related Change Request (CR) #: 7638

DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services News Flash – MLN Matters Special Edition Article #SE1128 titled “Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs),? reminds affected providers about their responsibilities to QMBs. This article is intended to help providers avoid inappropriately billing QMBs for Medicare cost- sharing, including deductible, coinsurance, and copayments.

MLN Matters® Number: MM7638 Related Change Request (CR) #: 7638

Related CR Release Date: December 2, 2011 Effective Date: April 1, 2012

Related CR Transmittal #: R2363CP Implementation Date: April 2 , 2012

April 2012 Quarterly Update for the Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

  • Provider Types Affected
    This article is for providers and suppliers submitting claims to Medicare Durable Medical Equipment Medicare Administrative Contractors (DME MACs), or Medicare Regional Home Health Intermediaries (RHHIs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provided to Medicare beneficiaries.
  • Provider Action Needed
    This article is based on Change Request (CR) 7638, which provides the DMEPOS April 2012 quarterly update. This update implements necessary changes to the Healthcare Common Procedure Coding System (HCPCS), ZIP code, and single payment amount files effective April 1, 2012. Be sure your billing staff is aware of these changes.
  • Background
    Section 302 of the Medicare Modernization Act of 2003 (MMA) established requirements for a new competitive bidding program for certain DMEPOS. Under the program, DMEPOS suppliers compete to become Medicare contract suppliers by submitting bids to furnish certain items in competitive bidding areas, and the Centers for Medicare & Medicaid Services (CMS) awards contracts to enough suppliers to meet beneficiary demand for the bid items. The new, lower payment amounts resulting from the competition replace the Medicare DMEPOS fee schedule amounts for the bid items in these areas. All contract suppliers must comply with Medicare enrollment rules, be licensed and accredited, and meet financial standards. The program sets more appropriate payment amounts for DMEPOS items while ensuring continued access to quality items and services, which will result in reduced beneficiary out-of-pocket expenses and savings to taxpayers and the Medicare program. Under the MMA, the DMEPOS Competitive Bidding Program was to be phased in so that competition under the program would first occur in 10 areas in 2007. As required by law, CMS conducted the Round One competition in 10 areas and for 10 DMEPOS product categories, and successfully implemented the program on July 1, 2008, for two weeks before the contracts were terminated by subsequent law. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) temporarily delayed the program in 2008, terminated the Round One contracts that were in effect, and made other limited changes. As required by MIPPA, CMS conducted the supplier competition again in 2009, referring to it as the Round One Rebid.
    The Round One Rebid Competitive Bidding Program was implemented on January 1, 2011, in CBAs defined by ZIP codes within nine of the largest Metropolitan Statistical Areas (MSAs). The CBAs in the Round One Rebid include: Charlotte-Gastonia-Concord, NC-SC; Cincinnati-Middletown, OH-KY-IN; Cleveland-Elyria-Mentor, OH;Dallas-Fort Worth-Arlington, TX; Kansas City, MO-KS; Miami-Fort Lauderdale-Pompano Beach, FL; Orlando- Kissimmee, FL; Pittsburgh, PA; and Riverside-San Bernardino-Ontario, CA.
    The Round One Rebid competitive bidding product categories are: Oxygen Supplies and Equipment; Standard Power Wheelchairs, Scooters, and Related Accessories; Group 2 Complex Rehabilitative Power Wheelchairs and Related Accessories; Mail-Order Diabetic Supplies; Enteral Nutrients, Equipment and Supplies; Continuous Positive Airway Pressure (CPAP) Devices, Respiratory Assist Devices, and Related Supplies and Accessories; Hospital Beds and Related Accessories; Walkers and Related Accessories; and, in the Miami-Fort Lauderdale-Pompano Beach CBA only, Support Surfaces (Group 2 Mattresses and Overlays). A list of the HCPCS codes that are included in each of the Round One Rebid product categories can be accessed by visiting the Competitive Bidding Implementation Contractor’s (CBIC) website at-CLICK-HERE on the Internet.
    MIPPA requires the competition for Round Two to occur in 2011 in 70 additional
    Metropolitan Statistical Areas (MSAs) and authorizes competition for national mail
    order items and services after 2010. The Affordable Care Act expands the number of Round Two MSAs from 70 to 91 areas and mandates that all areas of the country are subject either to DMEPOS competitive bidding or payment rate adjustments using competitively bid rates by 2016. You can find additional information on the DMEPOS Competitive Bidding Program aT-CLICK-HERE on the CMS website.
  • Competitive Bidding ZIP Codes
    For competitive bidding, ZIP codes designated as mail order only are assigned a
    separate CBA number from the standard CBA. ZIP codes are established by the
    United States Postal Service (USPS). The CBA numbers and associated names are
    as follows:
     16740 – Charlotte-Gastonia-Concord, NC-SC (non-mail order and mail order)
     16741 – Charlotte-Gastonia-Concord, NC-SC (mail order only)
     17140 – Cincinnati-Middletown, OH-KY-IN (non-mail order and mail order)
     17141 – Cincinnati-Middletown, OH-KY-IN (mail order only)
     17460 – Cleveland-Elyria-Mentor, OH (non-mail order and mail order)
     17461 – Cleveland-Elyria-Mentor, OH (mail order only)
     19100 – Dallas-Fort Worth-Arlington, TX (non-mail order and mail order)
     19101 – Dallas-Fort Worth-Arlington, TX (mail order only)
     28140 – Kansas City, MO-KS (non-mail order and mail order)
     28141 – Kansas City, MO-KS (mail order only)
     33100 – Miami-Fort Lauderdale-Pompano Beach, FL (non-mail order and mail order)
     33101 – Miami-Fort Lauderdale-Pompano Beach, FL (mail order only)
     36740 – Orlando- Kissimmee, FL (non-mail order and mail order)
     36741 – Orlando
    Kissimmee, FL (mail order only)
     38300 – Pittsburgh, PA (non-mail order and mail order)
     38301 – Pittsburgh, PA (mail order only)
     40140 – Riverside-San Bernardino-Ontario, CA (non-mail order and mail order)
     40141 – Riverside-San Bernardino-Ontario, CA (mail order only)
  • Single Payment Amount
    Currently, Medicare payment for most DMEPOS items is based on fee schedules in most areas of the country. However, the Social Security Act (Section 1847; see-CLICK-HERE on the Internet) mandates that competitive bidding single payment amounts replace the current DMEPOS fee schedule payment amounts for competitively bid items in CBAs. Therefore, the single payment amount is the Medicare allowed payment amount for competitively bid items for beneficiaries who reside in the Round One Rebid CBAs. Medicare pays contract suppliers 80 percent of the single payment amount for each competitively bid item. Beneficiaries are responsible for the remaining 20 percent of the single payment amount. Payment for all claims is on an assignment-related basis. In no case can a beneficiary be charged more than the 20 percent coinsurance payment for medically necessary items. Single payment amounts remain the same throughout the term of suppliers’ contracts.
    In the CBA pricing file and the single payment amount public use file, the rental single payment amounts for capped rental DME and rented enteral nutrition equipment are 10 percent of the purchase single payment amount. This payment amount is for rental months one through three. The rental single payment amounts for months 4 through 13 for capped rental DME and for months 4 through 15 for rented enteral nutrition equipment are equal to 75 percent of the single payment amounts paid in the first three rental months. The changes to the power wheelchair payment rules made by section 3136 of the Affordable Care Act see-CLICK-HERE on the Internet) do not apply to payment made for items furnished pursuant to competitive bidding contracts entered into prior to January 1, 2011, or for power wheelchairs in which the first rental month occurred before January 1, 2011. Therefore, under the Round One Rebid Competitive Bidding Program, contract and grandfathered suppliers furnishing rented power wheelchairs will continue to be paid under the capped rental payment methodology using 10 percent of the purchase single payment amount (or fee schedule amount for grandfathered suppliers) for the first three months and 75 percent of the single payment amounts (or fee schedule amounts for grandfathered suppliers) paid in the first three rental months for months 4 through 13. Similarly, the elimination of the lump sum purchase option for standard power wheelchairs, as required by the Section 3136 of the Affordable Care Act, does not apply to standard power
    wheelchairs furnished by contract suppliers under the Round One Rebid Program.
    Payment for standard power wheelchairs will continue to be made to Round One
    Rebid contract suppliers on either a lump sum purchase or rental basis.
    For inexpensive and/or routinely purchased DME items, the recorded single payment amount for rental is 10 percent of the purchase single payment amount.
    For all equipment furnished on a purchase basis, the recorded single payment
    amount for purchased used equipment is 75 percent of the purchase single payment amount.
    Also included in the CBA pricing file and the single payment amount file is the
    maintenance and servicing single payment amounts for rented enteral nutrition
    infusion pumps “(external)described by HCPCS code B9000 and B9002, made in accordance with the “Medicare Claims Processing Manual” (Chapter 20, Section 40.3; see-CLICK-HERE”:http://www.cms.gov/Manuals/downloads/clm104c20.pdf on the CMS website).
    The maintenance and servicing single payment amounts are equal to 5 percent of the single payment amount purchase price for the infusion pump.
  • Key Points of CR7638
    Updates to the ZIP Code Files:
    There are no updates to these files at this time
    Updates to the HCPCS and Single Payment Amount Files:
    There are no updates to these files at this time.