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Medicare DME Reimbursement Increases in 2020

Good news!

On January 1, 2020, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:

Depth Shoes (A5500): pair $147.74
Prefabricated, Heat Molded Inserts (A5512): pair $60.26
Custom Milled Inserts (A5514): pair $89.92

Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $328.52
Depth Shoes w/3 pr. Custom Molded Inserts: $417.50

Custom Molded Shoes w/offset heels and rocker bottoms: $585.26

Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1216.57, Floor $912.42
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2433.14, Floor $1824.84

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:

https://www.cms.gov/medicaremedicare-fee-service-paymentdmeposfeescheddmepos-fee-schedule/dme20a

Correct Coding – RT and LT Modifier

Until now, suppliers billing for bilateral DME devices including therapeutic shoes for patients with diabetes, diabetic inserts, custom AFOs or custom foot orthoses, have been able to submit electronic claims by indicating the total quantity and using the RTLT modifier on a single line OR by using RT on one line and LT on another, noting half the quantity on each.

Beginning March 1, 2019, such claims MUST be submitted using two separate lines, using the RT and LT modifier on each. Units of service (UOS) should be “1″ on each line for shoes and for AFOs; it should be up to “3″ on each line, for prefabricated or custom diabetic inserts. Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and / or LT modifier or with RTLT on a single claim line, will be rejected as incorrect coding.

Suppliers who have been submitting codes for bilateral devices using one line are advised to start billing on two separate lines NOW and not wait until March 1.

As always, each claim line should also include the modifier KX to indicate that all required compliance documentation is on file. When billing L3000 for custom foot orthotic devices, the GY modifier should be used to indicate that the item is statutorily excluded and cause the claim to deny.

For a link to the Medicare carrier website and Policy Articles, see:

https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/2018/correct-coding-rt-and-lt-modifier-usage-change

Medicare DME Reimbursement Increases in 2019

Good news!
On January 1, 2019, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Depth Shoes (A5500): pair $146.42
Prefabricated, Heat Molded Inserts (A5512): pair $59.72
Custom Milled Inserts (A5514): pair $89.12
Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $325.36
Depth Shoes w/3 pr. Custom Molded Inserts: $413.78
Custom Molded Shoes w/offset heels and rocker bottoms: $656.62
Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1178.61, Floor $904.29
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2357.22, Floor $1808.58

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME19-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

MIPS DRIVES SUCCESS BY PROMOTING FALL RISK ASSESSMENT, FITTING SHOES, ORTHOSES & AFOS

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit quality measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increased to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when balance AFOs, payable by Medicare, should be prescribed.

DON’T BE HIT WITH MIPS PENALTIES: DOWNLOAD THE LATEST MIPS FALL RISK ASSESSMENT TOOL HERE

MIPS quality measures 154, falls risk assessment and 155, falls, plan of care, address falls being the leading cause of injuries for older adults. One in four Americans aged 65 and over falls each year. By identifying people with gait instability, podiatrists can reduce this risk and make fall prevention a valuable part of their practice.

Physicians should annually, ask every patient, 65 and over, whether they have fallen in the past year. If so, they should follow-up by asking how many times and if the patient suffered an injury. Patients who have fallen two or more times or once with injury are defined to be at high risk.

These patients should be evaluated using a fall risk assessment form available from SafeStep.
Gait, strength and balance are assessed by having patients perform a “Timed Up and Go Test”. Patients stand, walk 10 feet, turn around and sit down. If TUG takes more than 12 seconds, there’s a good chance such conditions as: muscle weakness, difficulty walking or unsteadiness on feet are present.

MIPS 154 also requires assessing another contributing factor to falling including:
• a review of medications, or
• asking if the patient has had an eye exam in the past year, or
• reviewing other possibly contributing medical conditions, or
• determining the presence of postural hypotension.

Patients should be provided with a Plan of Care that includes balance, strength and gait training instructions, advice about vitamin D and information about home fall hazards. To make it easy, when using the assessment form available from SafeStep, simply tear off and give the patient a sheet that’s part of it.

When patients have NOT fallen two or more times or once with injury, submit MIPS quality measure 154 using CPT code 1101F.

If patients at high risk for falls are evaluated and provided a plan of care, consider billing E&M code 99213. Also submit codes 3288F and 1100F for MIPS 154 and 0518F for MIPS 155.
When there is fall risk, based on gait assessment, consider prescriptions for balance footwear, foot orthotics and possibly balance AFOs.

SafeStep has available, for free, copies of a Fall Risk Assessment form that assists in satisfying the MIPS fall prevention requirements. Medicare compliance documentation for AFOs can be best assured by using SafeStep’s WorryFree DME program.

Medicare DME Reimbursement Increases in 2018

Good news!
On January 1, 2018, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Depth Shoes (A5500): pair $143.12
Prefabricated, Heat Molded Inserts (A5512): pair $58.38
Custom Molded Inserts (A5513): pair $87.12
Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $318.26
Depth Shoes w/3 pr. Custom Molded Inserts: $404.48
Custom Molded Shoes w/offset heels and rocker bottoms: $570.38
Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1178.61 Floor $883.96
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2357.22 Floor $1767.92

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME18-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

MIPS DRIVES SUCCESS BY PROMOTING CDFE AND SHOE FITTING IN 2018

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit qualify measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increases to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when shoes and inserts, payable by Medicare, should be prescribed.

MIPS quality measures 126 and 127, diabetic foot exam including evaluation of footwear, address the association of neuropathy with diabetic foot ulceration. Properly fit shoes have been demonstrated to significantly reduce the likelihood of foot ulceration in patients with diabetes. By identifying people who qualify for shoes paid for by Medicare, podiatrists can make shoe fitting a valuable part of their practice.
Podiatrists should annually perform an ulcerative risk assessment on every patient with diabetes. A CDFE should include testing for loss of protective threshold using a 10-gram monofilament plus at least one of the following neurological exams including feeling vibration using a tuning fork, pinprick sensation, or ankle reflexes. Testing should also look for vascular, dermatological and structural findings. The foot should be sized using a standard measuring device, and the patient counseled on appropriate footwear based on risk categorization.

Patients with Medicare and diabetes who are identified to be at increased risk for ulceration should be fit with shoes and inserts. Shoe fitting will be most successful when patients are recommended models based on the consideration of what’s referred to as the 4 S’s of shoe fitting: Size, Shape, Stability & Style.

When patients with diabetes are given a comprehensive diabetic foot exam and provided a plan of care, which may include prescribing shoes, consider billing E&M code 99213. Also, submit codes G8404 for MIPS 126 and G8410 for MIPS 127.

SafeStep has available, for free, copies of a CDFE form that assists in satisfying the MIPS diabetic foot examination requirements. Medicare compliance documentation for diabetic shoe-fitting can be best assured by using SafeStep’s WorryFree DME program.

To access SafeSTep training and webinars, visit:

DME Training

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New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same.  For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

What is the Difference Between the PDAC and the DME MACs?

Function of the PDAC

One function of the Pricing Data Analysis and Coding Contractor is to determine an appropriate Healthcare Common Procedure Coding System (HCPCS) code to use when submitting claims to Medicare. A HCPCS code identifies the durable medical equipment, prosthetics, orthotics, and/or supplies (DMEPOS) being billed.

PDAC Responsibilities

  • Operate a Contact Center to provide coding advice and guidance
  • Maintain DMECS, a web-based interactive tool that provides HCPCS coding assistance and national fee schedule information
  • Respond to written inquiries requesting HCPCS coding assistance
  • Coordinate and participate in requests for HCPCS Coding Verification Reviews
  • Maintain a NDC/HCPCS crosswalk applicable for DME MAC billing

Who is Calling the PDAC?

  • Suppliers
  • Manufacturers
  • Distributors
  • OIG (Office of Inspector General)
  • CMS (Centers for Medicare & Medicaid Services)
  • Consultants
  • Attorneys
  • Doctor Offices
  • Pharmacies
  • Billing Services
  • Other Insurance Carriers
  • DME MACS
  • Medicaid
  • Attorney General Office

PDAC Can:

  • Provide HCPCS coding determinations
  • Provide allowables for items that are on the DMEPOS Fee Schedule

PDAC Cannot:

  • Provide codes for items that are not billable to the DME MACS
  • Answer coverage or policy questions including the use of modifiers
  • Address claim inquiries
  • Provide beneficiary eligibility
  • Assist with questions concerning claim form(s)
  • Address required documentation for claims submission
  • Provide allowables for items that are not on the DMEPOS Fee Schedule
  • Provide publications such as the Supplier Manual, bulletins or DMEPOS Fee Schedules
  • Address CMN or DIF Information
  • Assist with Type of Service or Place of Service codes
  • Provide Diagnosis Codes

Type of Calls Referred to the DME MAC:

  • Coverage and Utilization Questions
  • Eligibility
  • Claim Inquiries
  • Claim Form(s)
  • Required Documentation
  • Allowables for items priced by reasonable charge and individually considered items
  • Publications: Supplier Manual, bulletins and Fee Schedules
  • CMN/DIF Information
  • Type of Service and Place of Service Codes

Results of Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4360, L1970 and L1960)

Review Results

Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of HCPCS codes L4360, L1970 and L1960. This review was initiated based on CERT analysis.

The L4360 review involved 101 claims of which 97 were denied. This resulted in an overall error rate of 97%.

The L1970 review involved 100 claims of which 80 were denied. This resulted in an overall error rate of 79%.

The L1960 review involved 100 claims of which 69 were denied. This resulted in an overall error rate of 68%.

Primary documentation errors that resulted in denial of claims

• 21% of L4360 claims received a denial as basic coverage criteria not met.

• 21% of L1970 claims received a denial as basic coverage criteria not met.

• 30% of L1960 claims received a denial as basic coverage criteria not met.

Medical records are insufficient to support basic coverage criteria.

BASIC COVERAGE CRITERIA: Ankle-foot orthoses are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

•  21% of L1970 claims received a denial as criteria 1,2,3,4 or 5 not met.

•  32% of L1960 claims received a denial as criteria 1,2,3,4 or 5 not met.

1 of the 5 following criteria were not met:

•  The beneficiary could not be fit with a prefabricated AFO; or

•  The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

•  There is a need to control the knee, ankle or foot in more than one plane; or

•  The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

• The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.

20% of L4360 claims received a denial as no proof of delivery submitted.

7% of L1960 claims received a denial as no proof of delivery submitted.

No proof of delivery submitted.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

• 42% of L4360 claims received a denial as no written or verbal order received.

• 7% of L1970 claims received a denial as no written or verbal order received.

• 5% of L1960 claims received a denial as no written or verbal order received.

No written or verbal order received.

All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary’s name

• Prescribing Physician’s name

• Date of the order and the start date, if the start date is different from the date of the order

• Physician signature (if a written order) or supplier signature (if verbal order)

 

For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and start date, if start date different than date of order

• Detailed description of the item(s)

• Physician signature and signature date

Going Forward

Based on high error rate, Noridian Administration Services will close this probe review and begin a widespread targeted review on HCPCS codes L4360, L1970 and L1960.

To review entire article please click here