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

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: 

• Inexpensive DME;
• Other DME or expensive DME; and
• 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): 

• KXXX1 – Durable Medical Equipment, Miscellaneous, the Purchase Price Does not Exceed $150
  
• KXXX2 – Durable Medical Equipment, Miscellaneous, the Purchase Price Exceeds $150
  
• KXXX3 – Wheelchair Component or Accessory, Miscellaneous, the Purchase Price Does not Exceed $150
  
• KXXX4 – Wheelchair Component or Accessory, Miscellaneous, the Purchase Price Exceeds $150
  
• KXXX5 – Repair part for Use with Beneficiary Owned Durable Medical Equipment, Other than Wheelchair, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified
  
• 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 orrental 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.

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.  

1  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.
2  Based on the average reasonable charges for all inexpensive wheelchair components or accessories from July 1, 1986, through June 30, 1987.
3  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.
4  Based on the average reasonable charges for all expensive wheelchair components or accessories from July 1, 1986, through June 30, 1987.