Effective Jan. 1, 2011, the Centers for Medicare & Medicaid Services (CMS) will establish durable medical equipment prosthesis, orthotics and supplies (DMEPOS) specialty code B5 for ocularists.

The American Society of Ocularists defines an ocularist as a “carefully trained technician skilled in the arts of fitting, shaping, and painting ocular prostheses.” In addition to creating ocular prostheses, the ocularist shows the patient how to handle and care for them, and provides long-term care through periodic examinations.

Patients who need to be referred to an ocularist usually fall into the following categories:

• Recent enucleation/evisceration
• Problems with an existing prosthesis
• Blind eyes requiring a scleral shell
• Congenital anophthalmia/microphthalmia

Patients with existing ocular prostheses often need to be referred to the ocularist for problems with either the surface condition of the prosthesis or problems with the fit of the prosthetic eye or scleral shell.

Services provided by the ocularist include:

• Cleaning
• Polishing
• Enlargement
• Reduction
• Replacement

Due to the requirements of most insurance policies, a written prescription from the referring physician or other appropriate eye care specialist often is required.

The Centers for Medicare & Medicaid Services released July 23 the October quarterly update for the 2010 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule.

As part of this update, the Alaska and Hawaii fee schedule amounts for HCPCS Level II code E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each are being revised to correct errors made in the calculation of the fee schedule amounts. Contractors are instructed to adjust previously processed claims for code E0973 with service dates on or after Jan. 1, if they are resubmitted as adjustments.

Also included in the October quarterly update, per Transmittal 686 (Change Request (CR) 6743), the claims filing jurisdiction for HCPCS Level II code L8509 Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type is changing from DME Medicare administrative contractors (MACs) to Parts A/B MACs/Part B carriers, effective Oct. 1.

Source: CMS Transmittal 2006, CR 7070, issued July 23

An Office of Inspector General (OIG) review of jurisdiction C Medicare payments for selected Durable Medical Equipment, Prosthetics and Supply (DMEPOS) claims submitted in 2007 found that modifier KX Specific required documentation on file was not effective in ensuring required supporting documentation was on file. Based on the June 2010 review, the OIG estimates that Palmetto Government Benefits Administrators (Palmetto GBA) and CIGNA Government Services (CGS) inappropriately paid approximately $137 million to suppliers.

For certain DMEPOS, suppliers must use modifier KX on filed Medicare claims to indicate the claims meet Medicare coverage criteria and that the suppliers have the required documentation on file.

The types of missing documentation included:

• proof of delivery,
• physician’s order,
• use or compliant use follow-up documentation, and
• physician’s statement.

The errors, according to the OIG report, occurred because Palmetto GBA’s and CGS’ electronic edits were ineffective. What’s more, CGS added modifier KX to claims at the request of suppliers who said they had erroneously failed to add it to their claims.

The Centers for Medicare & Medicaid Services (CMS) has begun mailing contract offers to winning bidders of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. The first round of the program is scheduled to begin Jan. 1, 2011 for contract suppliers and beneficiaries in nine areas of the country. CMS says it plans to announce the contract suppliers in September.

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In the July quarterly update for the 2010 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule, released May 7, codes A4336, E1036, L8031, L8032, L8629, and Q0506 were added to the HCPCS Level II file effective Jan. 1. The fee schedule amounts for these codes were established as part of this update and are effective for claims with service dates on or after Jan. 1. At the time of the release, contractors were instructed not to adjust claims for these codes with service dates on or after Jan. 1 that already were processed.

Since then, the Centers for Medicare & Medicaid Services (CMS) has rescinded that instruction and is now instructing contractors (in Transmittal 1993, dated July 1) to adjust claims for codes A4336, E1036, L8031, L8032, L8629, and Q0506 with service dates on or after Jan. 1, if brought to their attention.

Providers that did not get their Provider Enrollment, Chain and Ownership System (PECOS) enrollment applications approved by the July 6 deadline are getting a temporary reprieve. The Centers for Medicare & Medicaid Services (CMS) says it will not, for the time being, implement automatic rejections of claims submitted by providers that are not enrolled in PECOS. Until the automatic rejections are operational, submitted claims will continue to be reviewed and paid as usual.

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The 2011 Medicare Physician Fee Schedule (MPFS) proposed rule, issued June 25 by the Centers for Medicare & Medicaid Services (CMS), projects a negative 6.1 percent update to physician payment rates at the start of 2011. If you add to that the 2.2 percent update legislation recently awarded to physicians, which expires Nov. 30, and the negative 21.3 percent update, which subsequently applies Dec. 1, then physicians are really looking at ringing in the New Year with a negative 29.6 percent update—barring further Congressional intervention.

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An interim final rule issued by the Centers for Medicare & Medicaid Services (CMS) requires physicians and other eligible professionals (EPs) who order or refer most types of covered Medicare services and items to have an active record in the Provider Enrollment, Chain, and Ownership System (PECOS) much sooner than expected. A group of medical associations continues to urge CMS to reconsider the recent ruling. Read more »

For the past six months, suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) may have been unwittingly shortchanging their reimbursement. HCPCS Level II codes for separately billable DMEPOS repairs were not included in previous guidance released last year by the Centers for Medicare & Medicaid Services (CMS), which went into effect Jan. 1.

Change Request (CR) 6914 amends attachment A of CR 6573 with the following list of HCPCS Level II repair codes that may be billed separately under the billing guidelines established in CRs 6573 and 5917.

Code                Description

K0739                Repair or non-routine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

L7500               Repair of prosthetic device, hourly rate

L7510                Repair of prosthetic device, repair or replace minor parts

L7520                Repair prosthetic device, labor component, per 15 minutes

L8627                Cochlear implant, external speech processor, component, replacement

L8628                Cochlear implant, external controller component, replacement

L8629                Transmitting coil and cable, integrated, for use with cochlear implant device

Q0506                Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

Effective Jan. 1 through Oct. 4, DMEPOS suppliers may bill separately for any of the repair codes included in this list in addition to the codes for replacement parts, accessories, and supplies for prosthetic implants and surgically implanted DME previously communicated in attachment A of CR 6573. Contractors will continue to process claims for these codes according to the guidelines established by CRs 5917 and CR 6573.

An interim final rule with comment period (IFC), which the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register on May 5, implements provisions in the Patient Protection and Affordable Care Act (Health Reform law). The provisions serve to promote quality health care and eliminate fraud and abuse in high-risk areas by enforcing stricter provider enrollment and claims submission requirements.

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