After implementing the 2021 DME and PEN fee schedules, CMS identified rate calculation errors affecting 364 unique HCPCS. The DME MAC contractors, however, will not automatically reprocess 2021 service dates processed before January 26, 2021. As such, suppliers should determine the benefit of any adjustment and, as applicable, request a reopening before the end of the year.
Which Suppliers Benefit?
There are very few cases in which the revised fee schedule rates negatively impact suppliers in non-continental areas. Suppliers in Hawaii, Alaska, Puerto Rico, and the Virgin Islands will see a few decreases, but they are much more likely to find an overall net benefit in reprocessing affected claims.
While the fee schedule does contain numerous reductions for other areas, nearly all the HCPCS with negative fee schedule changes apply to wheelchair accessories billed with the KE modifier in non-rural areas. The distinction is important because suppliers do not routinely use the KE modifier in non-rural areas. Instead – and only when appropriate – suppliers attach it to accessories in rural and non-continental areas largely spared from downward corrective adjustments.
The revised schedule contained no changes for suppliers of:
To illustrate the impact of potential fee schedule changes, we provide two sample claim comparisons:
Which Suppliers Benefit?
There are very few cases in which the revised fee schedule rates negatively impact suppliers in non-continental areas. Suppliers in Hawaii, Alaska, Puerto Rico, and the Virgin Islands will see a few decreases, but they are much more likely to find an overall net benefit in reprocessing affected claims.
While the fee schedule does contain numerous reductions for other areas, nearly all the HCPCS with negative fee schedule changes apply to wheelchair accessories billed with the KE modifier in non-rural areas. The distinction is important because suppliers do not routinely use the KE modifier in non-rural areas. Instead – and only when appropriate – suppliers attach it to accessories in rural and non-continental areas largely spared from downward corrective adjustments.
The revised schedule contained no changes for suppliers of:
- Diabetic shoes or testing supplies.
- Prosthetics or orthotics billed with L-codes.
- Former bid products in competitive bid areas.
To illustrate the impact of potential fee schedule changes, we provide two sample claim comparisons:
Requests to reprocess affected claims will affect all included items, not just those that yield a larger payment. Suppliers should evaluate the list of corrected HCPCS (see below) and determine the expected net benefit of reprocessing claims before taking any action. Reopening requests are due within 12 months of the original remittance, so suppliers should file requests well before December 31, 2021.
Affected HCPCS include:
A4557, A4563, A4595, A4604, A4636, A4637, A4640, A6550, A7000, A7003, A7004, A7005, A7006, A7007, A7010, A7012, A7013, A7014, A7015, A7017, A7018, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4149, B4150, B4152, B4153, B4154, B4155, B9002, E0130, E0135, E0140, E0141, E0143, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159, E0160, E0161, E0163, E0165, E0167, E0168, E0170, E0171, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0193, E0196, E0197, E0199, E0250, E0251, E0255, E0256, E0260, E0261, E0271, E0272, E0275, E0276, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0301, E0302, E0303, E0304, E0305, E0310, E0316, E0325, E0326, E0371, E0372, E0373, E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E0447, E0470, E0471, E0472, E0561, E0562, E0565, E0570, E0572, E0585, E0601, E0621, E0627, E0629, E0630, E0635, E0636, E0705, E0720, E0730, E0731, E0776, E0910, E0911, E0912, E0940, E0950, E0951, E0952, E0953, E0954, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0971, E0973, E0974, E0978, E0981, E0982, E0985, E0990, E0992, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1015, E1016, E1020, E1028, E1029, E1030, E1031, E1035, E1036, E1037, E1038, E1039, E1225, E1226, E1372, E1390, E1391, E1392, E1405, E1406, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2228, E2231, E2310, E2311, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2351, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2402, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2611, E2612, E2613, E2614, E2615, E2616, E2619, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633, K0001, K0002, K0003, K0004, K0006, K0007, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0195, K0733, K0738, K0800, K0801, K0802, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, and K0829.
SOURCE LINKS
https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center
https://www.cms.gov/medicaremedicare-fee-service-paymentdmeposfeescheddmepos-fee-schedule/dme-21ar
Affected HCPCS include:
A4557, A4563, A4595, A4604, A4636, A4637, A4640, A6550, A7000, A7003, A7004, A7005, A7006, A7007, A7010, A7012, A7013, A7014, A7015, A7017, A7018, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4149, B4150, B4152, B4153, B4154, B4155, B9002, E0130, E0135, E0140, E0141, E0143, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159, E0160, E0161, E0163, E0165, E0167, E0168, E0170, E0171, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0193, E0196, E0197, E0199, E0250, E0251, E0255, E0256, E0260, E0261, E0271, E0272, E0275, E0276, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0301, E0302, E0303, E0304, E0305, E0310, E0316, E0325, E0326, E0371, E0372, E0373, E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E0447, E0470, E0471, E0472, E0561, E0562, E0565, E0570, E0572, E0585, E0601, E0621, E0627, E0629, E0630, E0635, E0636, E0705, E0720, E0730, E0731, E0776, E0910, E0911, E0912, E0940, E0950, E0951, E0952, E0953, E0954, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0971, E0973, E0974, E0978, E0981, E0982, E0985, E0990, E0992, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1015, E1016, E1020, E1028, E1029, E1030, E1031, E1035, E1036, E1037, E1038, E1039, E1225, E1226, E1372, E1390, E1391, E1392, E1405, E1406, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2228, E2231, E2310, E2311, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2351, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2402, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2611, E2612, E2613, E2614, E2615, E2616, E2619, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633, K0001, K0002, K0003, K0004, K0006, K0007, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0195, K0733, K0738, K0800, K0801, K0802, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, and K0829.
SOURCE LINKS
https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center
https://www.cms.gov/medicaremedicare-fee-service-paymentdmeposfeescheddmepos-fee-schedule/dme-21ar
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