The Centers for Medicare & Medicaid Services (CMS) released its final 2020 alphanumeric Healthcare Common Procedure Coding System (HCPCS) update. The file includes HCPCS procedure and modifier codes, their long and short descriptions, and associated information on Medicare coverage and pricing.  CMS also has summarized its final determinations regarding HCPCS applications discussed at its

The Centers for Medicare & Medicaid Services (CMS) has adopted — with limited changes — its controversial plan to rewrite Medicare pricing rules for new items of durable medical equipment (DME), prosthetics, orthotics and supplies (DMEPOS) as part of its annual DMEPOS policy update for calendar year (CY) 2020.  The rule also makes minor changes to DMEPOS competitive bidding program (CBP) rules, streamlines certain requirements for ordering DMEPOS items, and makes other related policy changes.  The rule is effective January 1, 2020.

Revised Pricing Policy for New DMEPOS

CMS currently uses an arcane “gap-fill” process to establish rates for new DMEPOS items.  In short, if pricing is not available for the item in the statutory “base year” (1986 or 1987, depending on the item), CMS considers current fees for comparable items, supplier prices, manufacturer’s suggested retail prices (MSRPs), or wholesale prices.  That amount is then subject to a series of deflation adjustments and statutory updates to achieve the new Medicare rate.  CMS’s reliance on the pricing of existing products has been a point of contention when a manufacturer does not believe any items currently on the market are comparable to the innovative technology.  At the same time, CMS does not believe that MSRPs “represent accurate pricing from actual retail markets.”

To “improve … transparency and predictability,” CMS is adopting a new framework for setting fees for new DMEPOS items (i.e., new Healthcare Common Procedure Coding System (HCPCS) codes that do not have a fee schedule pricing history).  As it proposed, CMS will first seek to use existing fee schedule amounts for DMEPOS that it determines to be “comparable” based on the following five components and attributes (the new product does not need to be comparable within each category, and there is no prioritization of the categories):
Continue Reading CMS Updates Medicare DMEPOS Policies, Including Overhaul of Pricing Framework for New HCPCS Codes

Agency Promises More Frequent Drug/Device HCPCS Code Update Opportunities, Bars MACs from Adopting New Blanket Noncoverage Policies without Evidence Review  

On May 2, 2019, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma outlined new improvements to the HCPCS coding and local coverage decision processes that are intended to “ensure safe and effective treatments

CMS has announced the schedule for public meetings on pending applications for new or revised HCPCS codes for calendar year 2020:

May 13-15, 2019 — Drugs/Biologicals/ Radiopharmaceuticals/Radiologic Imaging Agents.

June 11-12, 2019 — Durable Medical Equipment and Accessories, Orthotics and Prosthetics and Supplies, and Other

CMS intends to release the agenda and preliminary coding determinations

James Bailey is the new CMS Medicare Pharmaceutical and Technology Ombudsman, a role Congress established in the 21st Century Cures Act to help expedite resolution of industry Medicare reimbursement concerns. The Ombudsman’s office is charged with fielding questions from pharmaceutical, biotechnology, medical device, diagnostic product manufacturers, and other stakeholders regarding Medicare coverage, coding, and

CMS has just announced the dates for its annual meetings to discuss pending applications for new and revised HCPCS codes:

May 16 – 18, 2017: Drugs/Biologicals/Radiopharmaceuticals/Radiologic Imaging Agents

June 7 – 8, 2017: Durable Medical Equipment and Accessories/Orthotics and Prosthetics/Supplies/Other

Deadlines and instructions for speaker and general registration and submission of comments are set forth

Included in the 21st Century Cures Act are numerous changes to Medicare and Medicaid policies, including provisions with significant reimbursement impacts for certain types of Medicare providers and suppliers, along with changes intended to reduce the regulatory and administrative burdens associated with the use of electronic health records.  Furthermore, the law once again expands the

On October 1, 2016, CMS is definitively ending an ICD-10 coding “flexibility” policy announced last year that prevents practitioner Medicare Part B physician fee schedule claims from being denied based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/practitioner uses a valid ICD-10 code from the right family.  According to

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have issued a Correct Coding article on “HCPCS Coding Recommendations from Non-Medicare Sources,” which discusses Medicare supplier responsibility for selecting the most appropriate Healthcare Common Procedure Coding System (HCPCS) code for furnished medical products. The DME MACs point out that manufacturers and other entities

The HHS Office of Inspector General (OIG) recently issued a report examining implementation of Medicaid National Correct Coding Initiative (NCCI) edits, as required by the Affordable Care Act since October, 2010.  The report finds that several problems have limited the success of these edits (medically unlikely edits and procedure-to-procedure edits), which are designed to encourage

On August 27, 2015, CMS is hosting a call to help health care providers prepare for ICD-10 implementation on October 1, 2015. CMS staff will be joined by representatives of the American Health Information Management Association (AHIMA) and the American Hospital Association (AHA). The call will cover: the status of implementation, coding guidance; how to

CMS is proposing to revise the coding used to describe miscellaneous durable medical equipment (DME). The agency notes that HCPCS code E1399, “durable medical equipment, miscellaneous,” is currently used to bill for inexpensive DME, other covered DME, and replacement parts, which are subject to different payment rules. Likewise, HCPCS code K0108 describes a “wheelchair component or accessory, not otherwise specified” and is currently being used to bill for inexpensive DME, other covered DME, and replacement parts of wheelchairs. To promote more accurate payment of Medicare DME claims, CMS is proposing replace HCPCS codes E1399 and K0108 with the following HCPCS codes, effective January 1, 2016:Continue Reading CMS Proposes HCPCS Changes for Miscellaneous DME

CMS is hosting a call on November 5, 2014 to discuss implementation issues associated with the transition to ICD-10 on October 1, 2015. The call will cover the following topics: final rule and national implementation; Medicare Fee-For-Service testing; the Medicare Severity Diagnosis Related Grouper (MS-DRG) Conversion Project; partial code freeze and annual code updates; plans

HHS has published a final rule that makes official the October 1, 2015 compliance date for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). HHS had previously intended to transition from ICD-9 to ICD-10 on October 1, 2014, but the Protecting