MiraVista: Medicare News Blog

Three New Draft Policies Released by CMS – Lower Limb Policy Heavily Impacted

July 30th, 2015

Angela Hayden

 

CMS has released three new draft LCDs for comment: Bowel Management Devices, External Infusion Pumps and Lower Limb prosthesis.  The External Infusion and Lower Limb drafts are revisions to the existing LCD, while the Bowel Management Device draft is a newly proposed LCD.

 

In the Bowel Management Device LCD draft, CMS breaks down a number of products including bed pans, incontinence garments and disposable underpads to clarify the coverage status of these items. In this proposed draft, CMS allows coverage for bed pans (E0275 & E0276), but continues to classify incontinence garments, disposable underpads and miscellaneous incontinence supplies as non-covered services.

 

In the External Infusion Pump draft policy, the coverage criteria for the administration of parenteral inotropic therapy has been significantly altered to include additional documentation requirements and monitoring for medical necessity. We strongly encourage suppliers of External Infusion Pumps and related drugs to review these changes prior to the comment deadline. Suppliers can find the draft policy on their DME MAC website.

 

The proposed draft of revisions to the Lower Limb Prosthesis LCD contains the most significant changes as the policy was essentially overhauled with new coverage criteria, policy requirements, documentation requirements and definitions.

 

The policy begins by defining: initial prosthesis, replacement prosthesis, immediate prosthesis, preparatory prosthesis, definitive prosthesis, new amputation, revised amputation and mature residual limb. In the new draft, there are three general groups that these products will be categorized under:  immediate (postoperative) prosthesis, preparatory prosthesis and definitive prosthesis.  Each category is then broken down into its own coverage and coding requirements. Overall though, coverage for these products will be dependent upon a qualifying amputation, when the prosthesis is supplied in the healing process and the beneficiary’s motivation to ambulate using the product.

 

Another major shift proposed in this draft is the requirement for an independent medical exam by a Licensed or Certified Medical Professional (LCMP) to determine the beneficiary’s functional status. This section also breaks down the medical professionals that are considered a Licensed or Certified Medical Professional (LCMP).  This additional documentation requirement alters the way that suppliers handle intake for these products.

Another new requirement in this draft requires new amputees to participate in a rehabilitation program prior to receiving a definitive prosthesis. In the rehab program the beneficiary must:

 

  • Don and doff the prosthesis without assistance,
  • Transfer without assistance both using and not using the prosthesis,
  • Have sufficient wear tolerance to use the prosthesis for a normal day’s activities,
  • Attain sufficient balance and stability to ambulate with ease of movement and energy efficiency with the preparatory prosthesis after final residual limb volume stabilization and prior to provision of the definitive prosthesis.

 

The prosthetist will be required to obtain information regarding the beneficiary’s participation in the rehab program which demonstrates the beneficiary is able to ambulate and manage the use of their preparatory prosthesis, and that that the residual limb is sufficiently mature and stable. This documentation must be on file in order to justify the provision of a definitive prosthesis.

 

The policy also revises the sections dedicated to the K –level functional modifiers with a dedicated section that describes each functional level. Repair and Replacement is also addressed in this revised policy to provide details on the approved scenarios for replacement and repair of these prosthetic devices.

 

Lastly, the draft contains new language in the Policy Specific Documentation Requirements section regarding the proper use of forms to facilitate record keeping. In this section it is states that CMS does not prohibit the use of templates, however, they also do not endorse or approve of any particular templates. The policy specifically “discourages” forms with check boxes, predefined answers or limited space for writing as these forms “often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met”.

 

CMS will be accepting comments on the above draft policies through the close of business on Monday, August 31, 2015. Comments must be submitted electronically to DMAC_Draft_LCD_Comments@athem.com.  The established contact for this process is Jurisdiction B Medical Director, Stacey V. Brennan, M.D, FAAFP.

 

CMS Will Forgive ICD-10 Errors for a Year After Implementation

July 22nd, 2015

Andrea Stark

 

CMS, in collaboration with the American Medical Association, issued an updated FAQ regarding ICD-10 concerns in early July 2015. In the notice, CMS indicated that ICD-10 errors regarding specificity would not be denied by Medical Review contractors for 12 months after implementation.

 

“While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

 

CMS will still be enforcing the requirement of a valid ICD-10 code post implementation, however the regulation on specificity as it pertains to medical review will be more relaxed for the next year for practitioner claims. While this relaxation does not directly impact DME claims, it may be a sign of future directives to contractors when editing based solely on diagnosis codes. Future LCDs for diagnosis driven DME products have already been posted to the CMS website. For DME claims like nebulizer equipment, accessories and medication or Group 2 support surfaces and CPAP equipment which are diagnosis driven, these documents will be the primary source of ICD-10 diagnosis enforcement. However in this announcement, CMS also indicated that they will be naming a CMS ICD-10 Ombudsman in the coming months to “triage and answer questions about the submission of claims”.

 

CMS has released a number of tools to assist providers in the transition including a General Equivalency Mapping and a dedicated ICD-10 webpage. If you have concerns about the speed and advancement of your company’s ICD-10 transition, MiraVista has put together a tool that will not only help you identify your most vulnerable codes, but it will also map them to the ICD-10 equivalent(s)…within minutes. Our programming team has created this tool utilizing the General Equivalency Mappings from CMS. The tool will plug in exported active rental data from your billing software and provide you with:

 

  • A list of your most popular ICD-9 codes so that you can educate your staff and referral sources.
  • A classification for each code determining whether it is a one-to-one or one-to-many match.
  • A mapping from each ICD-9 code to the ICD-10 equivalent(s).
  • A list of the order numbers appended to each diagnosis code so that you can quickly identify which patients require intervention.

 

If you are interested in additional details regarding this tool, please contact us at icd10@miravistallc.com.

 

CMS Officially Extends the PMD Demo until 2018

July 16th, 2015

Andrea Stark

 

On July 15th, CMS posted a notice to the Federal Register announcing the extension of the Prior Authorization Demonstration for Power Mobility Devices currently established in 19 states (CA, IL, MI, NY, NC, FL, TX, MD, NJ, PA, IN, KY, OH, GA, TN, LA, MO, WA, and AZ) through August 31, 2018. The demonstration was set to expire on August 31, 2015.

 

As a part of the demo, suppliers of select scooters and power wheelchairs are required to request prior authorization from their DME MAC in order to provide the power mobility equipment. Once an approved request is received, the supplier can then deliver and bill the equipment. The prior approval review of the medical necessity of the base is not subject to further prepayment review (audit by the DME MAC) although accessories and proof of delivery documents that are not eligible for prior authorization review can be subjected to further audit scrutiny.

 

The Power Mobility Demonstration was originally launched by CMS on September 1, 2012, as a three year project to require prior authorizations for certain Power Mobility Devices (PMDs) for patients residing in demonstration areas. The demo was rolled out in seven states initially.  The first seven states that CMS selected were chosen based on a high population of fraudulent and error prone suppliers: California, Florida, Illinois, Michigan, New York, North Carolina and Texas.

 

In April of 2014, CMS then posted a Federal Register notice seeking to expand the demonstration into 12 additional states: Arizona, Georgia, Indiana, Kentucky, Louisiana,  Maryland, Montana New Jersey, Ohio, Pennsylvania, Tennessee and Washington. At the close of the comment period, CMS found that responders were mostly in favor of the expansion, and the program was expanded in October of 2014.

 

Because of the success of this program (as reported by CMS) and in conjunction with industry support, the program has now been extended until August 31, 2018.  For details on the program see the CMS dedicated webpage here. To view the official release for the extension, click here.

 

CMS Accepting Comments Through July 9th on Misc HCPCS Coding Changes

July 8th, 2015

Angela Hayden

 

CMS has released a notice seeking comments on a proposal to replace two miscellaneous HCPCS with newer more descriptive HCPCS effective January 1, 2016. Currently, there are two DME HCPCS used by suppliers to code many different types of items across different fee schedule categories such as inexpensive DME, replacement parts, wheelchair accessories and other items that do not meet the definition of an existing HCPCS code:

 

  • E1399 (durable medical equipment, miscellaneous) and
  • K0108 (wheelchair component or accessory, not otherwise specified).

 

Effectively all miscellaneous HCPCS are a blank slate and mandate that additional details get submitted with the claim to identify the item and establish medical necessity and pricing details for effective processing. Because these codes are not linked to an existing fee schedule or LCD suppliers are required to provide a narrative description of the item including the product name, make/model of the item, and the manufacturer’s suggested retail price in order for the contractor to be able to consider the claim for payment.

 

In the June 18th proposal, CMS indicated that the current payment methodology for these miscellaneous codes are not being processed according to the governing federal guidelines stipulated in Title 42 of the Code of Federal Regulations Subpart Sections 414.220 (Inexpensive payment guidelines) & 414.229 (other covered DME payment guidelines) & 414.210(e) (wheelchair replacement parts payment guidelines). Because of this, CMS is seeking to migrate the existing miscellaneous HCPCS into three categories of codes so correct payment logic can be applied:

 

  1. Inexpensive DME;
  2. Other DME or expensive DME; and
  3. Replacement parts for DME being repaired.

 

Under this proposal CMS will replace HCPCS E1399 and K0108 with the following six codes (specific HCPCS yet to be established):

 

  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

 

The notice goes on to indicate that payment for items coded as KXXX5 and KXXX6 will be made on a lump sum purchase amount, which will be based on the contractor’s individual consideration of the item being billed.  For items coded as KXXX1 and KXXX3, payment will be made on a purchase or rental basis depending on the supplier’s actual charges (purchase price is $150 or less or the rental amount is $15 or less). Likewise for items coded as KXXX2 or KXXX4, payment will also be made on a purchase or rental basis when the supplier’s actual charges for purchase exceeds $150 or the rental cost exceeds $15. CMS also included the schedule and logic for maximum allowable for these codes (no matter the cost to the supplier). See the table below for a visual breakdown of these changes.

 

HCPCS RR NU  Fee Schedule
KXXX11 ≤ $15 ≤ $150  $   97.94
KXXX32 ≤ $15 ≤ $150  $   72.56

 

 

 

HCPCS RR NU  Rental Months 1-3  Rental Months 4-13
KXXX23 > $15 > $150  $   80.60  $   60.45
KXXX44 > $15 > $150  $   53.41  $   40.06

 

These fee schedule amounts will be revisited and updated based on the 2016 covered item update, when considering claims with date of service on an after January 1, 2016.  Overall, CMS is seeking to breakdown these miscellaneous codes to be more specific rather than catch all codes.  Electronic comments are being accepted by CMS through July 9, 2015. Suppliers that would like to submit a comment regarding these proposed changes can email those comments to codingcomments@cms.hhs.gov with “Miscellaneous Code Comments” as the subject.

 

 

Based on the average reasonable charges for all inexpensive DME items other than wheelchair components or accessories from July 1, 1986, through June 30, 1987.

Based on the average reasonable charges for all inexpensive wheelchair components or accessories from July 1, 1986, through June 30, 1987.

Based on the average reasonable charges for all expensive DME items other than wheelchair components or accessories from July 1, 1986,   through June 30, 1987.

Based on the average reasonable charges for all expensive wheelchair components or accessories from July 1, 1986, through June 30, 1987.

 

Updated Quantity Language for Enteral Impacts Claims Payment

June 29th, 2015

Andrea Stark

 

A new enforcement of quantity details on Detailed Written Orders for enteral nutrition is manifesting in claim denials. CGS recently updated the language on the Enteral Documentation Checklist (as of January 27, 2015) that mentions a new description for quantity on the Detailed Written Order to be represented on a “per fill” basis. This is new terminology and a compliance expectation that CGS and other MACs are now beginning to enforce. We have not seen these quantity errors in prior claims because the medical reviewers were using discretion to calculate proper quantities using other elements on the Detailed Written Order. However, because there are so many variations and fluctuations with the prescription and how claims are billed, they are now requiring the orders to be more specific to avoid denial. The Provider Education departments are also increasing their discussion of this expectation. The MACs are interpreting this nuance to be a part of the quantity requirement of the LCD.

 

This enforcement has been hardest felt in Jurisdiction C, but other MACs are incorporating this into their education as well. To avoid future denials, providers are encouraged to secure updated orders for nutrition that comply with the details of a per fill quantity:

 

Quantity to be dispensed (Should correspond with the total amount of each item to be provided per refill. This information may be expressed as cans, bottles/bags, cases, or billing units [1 unit=100calories]).

 

Under this new guidance the contractors are expecting language to appear on Detailed Written Orders along the lines of:

 

  • 1200 calories per day X 30 days X 12 refills
  • 120 units at 100 calories X 30 days X 12 refills
  • If the patient is on a formula that consists of 300 calories per can, the suitable example might read, 4 cans per day X 30 days X 12 refills.

 

If you provide enteral nutrition we encourage you to connect directly with your POE (Provider Outreach & Education) department of your MAC to confirm their expectations as there may be slight nuances from DME MAC to DME MAC. As additional details become available on this topic, MiraVista will keep you informed.

 

OMHA Takes Next Step for Improving the Third Level of Appeals

June 25th, 2015

Angela Hayden

 

The Office of Medicare Hearings and Appeals (OMHA) has announced the contract award for the next phase of process improvement for the third level of Medicare appeals (Administrative Law Judge or ALJ).  On March 30, 2015, CACI Inc. was awarded the development contract for the Electronic Case Adjudication and Processing Environment (ECAPE) for OMHA.  This tool is an effort to streamline the procedures of the ALJs after an exponential increase of third level appeals overwhelmed the office and pushed case assignment wait times to nearly two years. This tool will allow the ALJs to process cases electronically, and will feature functionality for:

 

  • Case and workload management,
  • Exhibiting,
  • Scheduling,
  • Document generation,
  • Electronic filing of requests for hearing and supporting documents, and
  • Enhanced management information and business intelligence.

 

Overall, this tool improves the internal process of the ALJs by streamlining case management from start to finish. Creating this electronic system will increase ease of access for all departments within the ALJ and expedite the resolution process.  This tool is expected to be rolled out in release phases.

 

The first release will tackle case intake and create an application called the Appellant Public Portal (APP).  The first release is anticipated for early 2016. The Appellant Public Portal (APP) is a sub-component of ECAPE. APP will allow appellants to file requests for hearings, submit additional evidence, check appeal status, and view the appeal case file online.  There are two separate phases that exist within APP deployment.  Phase one of APP will allow a guest user (without registration) to file a request for hearing online, check the status of an appeal and upload the additional relevant evidence to support the case. Phase two of APP will allow users that frequently file appeals to register as a user to file requests for hearing online, upload evidence, check appeal status, view case files, access electronic correspondence, and establish and maintain an appellant profile to expedite repetitive tasks.

 

The second release of ECAPE is expected in early 2017 and will encompass functionality for the remaining parts of the adjudication process from assignment to case closure.

 

The third and final release of ECAPE is also scheduled to take place in 2017 to address any enhancements needed to APP as well as other functionality not addressed in the first two releases. This is a major undertaking for the contractor, converting the current labor intensive manual process into an electronic process and streamlining communication channels.  Integrating paper documents into an electronic storage and management solution is an extensive process, but is expected to pay dividends for work flow purposes. Ultimately, this new tool will deploy functionality to improve the ALJ appeal process for both appellants and ALJs. OMHA has indicated that additional details will be provided via their listserve as the development of ECAPE progresses.

 

CBIC Backtracks & Removes Ventilators from Round 1 2017

June 9th, 2015

Angela Hayden

 

In a listserve posted on June 4th, 2015, the CBIC announced the removal of Non-Invasive Pressure Support Ventilators from Round 1 2017.  The E0464 was introduced as a stand-alone product category for this particular round of bidding in April 2015. Bidding for this round has not yet begun, which allows the CBIC to process these kinds of changes.

 

CMS has recently released a number of educational bulletins and Joint DME MAC publications to inform suppliers that Ventilators are not appropriate for the treatment of OSA and those conditions covered in the Respiratory Assist Device (RAD) policy (Complex Sleep Apnea, Central Sleep Apnea, Hypoventilation Syndrome, etc).  Because of advancements in technology, some ventilators are able to operate in PAP or RAD modes, therefore suppliers are incorrectly utilizing these ventilators in place of a PAP or RAD device.

 

With the announcement, CMS also announced plans to consolidate current ventilator codes into two codes effective December 31, 2015.  As of December 31st, the following codes will be obsolete:

 

  • 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)

 

CMS will replace the above codes with two new codes that have yet to be assigned, but will be effective January 1, 2016:

 

  • 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)

 

Exxx1 will be used in place of HCPCS E0450 and E0463, while Exxx2 will be used for HCPCS E0460, E0461, and E0464.  In terms of fee schedule, CMS will establish the fee schedule amounts for the new codes using the current fee schedule for E0450, which varies in allowable (depending on state) from $868.40 to $1,761.50.  CMS also noted in this bulletin that they “intend to closely monitor” the use of the newly established codes to ensure that items used for the treatment of OSA are not being billed under these codes.

 

CMS is accepting comments for consideration on these changes through 5pm on June 25, 2015 at codingcomments@cms.hhs.gov.  Suppliers that wish to submit a comment should make the subject line “Ventilator Comments”. See the official notice here.

 

New Bill Seeks Prior Authorization for Oxygen & Other High Cost DME

June 2nd, 2015

Angela Hayden

 

On May 19, 2015, HR 2437 was introduced by Tennessee Representative Marsha Blackburn.  This legislative piece seeks to require CMS to create and implement a prior authorization program (similar to that of the Power Mobility Device Demo) for high cost DMEPOS items, such as Oxygen which is specifically mentioned in the language of the bill.  The bill also has a provision to exempt claims that are approved for prior authorization from both pre-pay and post-pay audit.

 

Prior authorization has been an increasingly popular Medicare initiative for DMEPOS in the last few years. First with the live expansion of the PMD Prior Authorization demo into 12 new states and then with the introduction of a proposed rule to institute prior authorization for DMEPOS in general.  With HR 2437 we see a scaled down version of the proposal for DME prior authorization, which broadly discusses high cost DME, but specifically addresses Oxygen.

 

The bill requires the HHS Secretary to expedite emergency review of prior authorization requests to ensure same day delivery expectations can be met by suppliers for items such as Oxygen.

 

The regulation requires that stakeholder input be included in the development process and that priority be assigned to items that are subject to a high number of contractor audits (specifying Oxygen as a priority).

 

Overall the tone of the bill is positive and seeks to reduce the audit burden for suppliers providing high cost DME items through a prior authorization process.  To see the full text of the bill use this link: http://thomas.loc.gov/cgi-bin/query/z?c114:H.R.2437:.

ICD-10 is Back Again: Are you Ready?

May 26th, 2015

Angela Hayden

 

The transition to the ICD-10 diagnosis coding set is officially scheduled for October 1, 2015. Despite previous delays in deployment, the Department of Health and Human Services has not given any reason to expect any further deferments. That means we are just a few months away from ICD-10.

 

The transition from the ICD-9 diagnosis code set to ICD-10 will be a major undertaking for DME suppliers and should not be taken lightly. If you have not considered how ICD-10 will impact your business, now is the time. The ICD-10 code set is significantly more robust than the current ICD-9 which means that many ICD-9 codes will not crosswalk directly to a single ICD-10 code. Where there is a one-to-many link, claims will require manual intervention to be assigned the appropriate ICD-10 code for processing.

 

Communicating with your billing software vendor is an integral part of a successful transition. Your vendor may have tips or tools that can assist you with the migration of your claims from one code set to the other. As you communicate with your software vendor here are a few key questions to consider:

 

  • Will claims be cross-walked automatically by the vendor or will they require manual intervention by your staff?
  • Will there be a protocol for scrubbing claims prior to submission to ensure that codes have been transitioned appropriately? If so, what will this process look like and what will be required of your staff to move these claims forward?
  • Has the vendor participated successfully in the ICD-10 front-end and/or the end-to-end testing offered by CMS?

 

Keep in mind that CMS has implemented a hard cut off for the use of ICD-9 codes. This means that claims submitted with dates of service on and after October 1st containing ICD-9 codes will be returned as unprocessable.  Claims that are not proactively identified and transitioned will stall revenue.

 

***

Overwhelmed with the transition? We can help with that. 

 

MiraVista has put together a tool that will not only help you identify your most vulnerable codes, but it will also map them to the ICD-10 equivalent(s)…within minutes.  Our programming team has created a tool, utilizing the General Equivalency Mappings, which will plug in exported active rental data from your billing software and provide you with:

 

  • A list of your most popular ICD-9 codes so that you can educate your staff and referral sources.
  • A classification for each code determining whether it is a one-to-one or one-to-many match.
  • A mapping from each ICD-9 code to the ICD-10 equivalent(s).
  • A list of the order numbers appended to each diagnosis code so that you can quickly identify which patients require intervention.

 

For more information on this service please contact us at icd10@miravistallc.com.

 

CMS Releases Additional Guidance on National CB & Bundled Payments

May 14th, 2015

Andrea Stark

 

CMS has released an updated FAQ regarding the National Competitive Bidding (NCB) pricing expansion and the bundled payment demonstration.  In this updated FAQ, they published the 1993 fee schedule rates that will be the basis for the maximum bid limit for the Continuous Positive Airway Pressure Device bundled payment demonstration.

 

In the final rule, it was announced that CMS will test a bundled, continuous payment model for CPAP Devices and Standard Manual Wheelchairs. Before any bid program can begin, CMS must establish a maximum bid limit that suppliers cannot bid above.  This is typically set at the current fee schedule for a product in a given Competitive Bid Area (CBA). For Standard Manual Wheelchairs, CMS established that the bid limit will be based on the total payment amounts per month in the selected CBA for the base equipment, repair, maintenance, service and accessories used, divided by the total (unduplicated) number of beneficiaries receiving those items and services.  For CPAP, however, there is precedent as CMS has paid CPAP on a continuous bundled payment methodology in the past. Therefore, in the final rule CMS announced that the maximum bid limit for CPAP will be based on the maximum allowable from the 1993 fee schedule for CPAP.  That fee schedule amount was not initially released with the final rule; however, after corresponding with the CBIC representatives MiraVista discovered that the 1993 rates were then pushed in the updated FAQs.

 

Our starting point on the fee schedule is the national ceiling for CPAPs back when they were in the frequent and substantially serviced category and paid as a continuous rental with all accessories, labor and maintenance included in the reimbursement rate. The ceiling back in 1993 was listed at $122.25. With all the adjustments for increases and decreases for all years in between 1993 and 2015, we end up with a current ceiling of $137.08. However, individual state fee schedules vary, and if a beneficiary lived in NY, the fee schedule in 2015 would be $116.73. CMS could choose to set the national ceiling as the max bid rate, or use individual state fee schedules. Opting to use the individual state fee schedule would lower the max bid amount (meaning, to secure a contract, supplier would have to bid below the established maximum). Therefore, at the national rate supplier would bid a max rate below $137.08, but if state fees are used, NY bidders would not bid any higher than $116.73. The bid amount must cover the provision of  the base equipment, all accessories, supplies, repairs, maintenance and service on a monthly basis for as long as medically necessary.

 

We put together a hypothetical reimbursement scenario for an E0601 with a nasal mask provided in a non-CBA in New York. In this scenario the supplier is replacing supplies at the frequency outlined in the PAP LCD. This scenario assumes the supplier is reimbursed for the setup of the PAP, accessories and supplies and continues to replenish supplies until the 5 year RUL. On average, in this scenario, the supplier would be reimbursed a total of $6,171.87 over a five year period. This breaks down to $102.86 a month. Keep in mind that this does not include any repairs or replacement parts. If we were to contract at the maximum allowable for the bundled payment program at $137.08, over the same five year period the supplier would be reimbursed a total of $8,224.80. That breaks down to a $34.94 increase in total monthly reimbursement.

 

The above is a hypothetical breakdown designed to get you thinking about how this ruling will impact you as a supplier.  While we do not yet have the designated demo areas, CMS has indicated that there will be no more than 12 CBAs in total for the new demonstrations. We have been told they will not overlap. There are three demos in all: the standard manual wheelchair bundled payment demo, CPAP bundled payment demo and the modified repair requirements for standard power wheelchairs paid on a capped rental basis.  These demonstrations typically last 2-3 years before expanding.

 

Keep in mind that all pricing is subject to change in 2016 as CMS rolls out National Competitive Bidding pricing to all areas rural and the like.

 

This is one of the many ways that MiraVista uses data analytics to make complex information translate into actionable intelligence. Learn more about how you can use simple data mining techniques to empower your business in our upcoming webinar “AR on the Rise? Mine Your Data & Leverage Online Tools” on May 21st at 2:00pm. See the details and register on our website at http://www.miravistallc.com/recent_services.php.

 


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