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CMS/Medicare

News and analysis of CMS rules, Medicare policy and reimbursement changes affecting HME providers and home health agencies.

  • CO 50: Non-covered services not deemed a medical necessity

    CO 50, the sixth most frequent reason for Medicare claim denials, is defined as: non-covered services because this is not deemed a medical necessity by
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  • CO57: Payment denied/reduced

    The No. 3 denial reason code from Medicare among HME providers as reported by RemitData is CO57: Payment denied/reduced because the payer deems the information
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  • Latest CMS/Medicare News

  • CMS Proposes 18 New Codes For Power Wheelchairs

    Baltimore Last month, the Centers for Medicare and Medicaid Services (CMS) issued a proposal that includes 18 new power wheelchairs codes. The proposal was to be discussed at a four-hour public meeting that, at press time, was scheduled for Sept. 1 at the agency’s Baltimore headquarters. Part of a broader government effort to revamp Medicare’s wheelchair benefit, CMS’ coding task force received input from the SADMERC, DMERC medical directors and outside consultants to come up with the proposed codes. The group also studied national power wheelchair claims data over one year. The 18 codes are grouped into three broad categories — Standard, Heavy-Duty and Bariatric — that cover approximately 95 percent of typical code combinations currently billed under K0010, K0011, K0012 and K0014. The groupings…
    Read More →: CMS Proposes 18 New Codes For Power Wheelchairs

  • CMS Rolls Out Proposal for Drug Cuts, Face-to-Face Physician Exam

    Washington In a Notice of Proposed Rule Making published in the Aug. 5 Federal Register, CMS included respiratory drug reimbursement cuts for 2005 even more drastic than originally expected. The agency also issued its long-anticipated proposed regulation requiring Medicare beneficiaries to have a face-to-face examination from a physician before receiving a power wheelchair. But in an unexpected turn, the proposal calls for face-to-face patient exams for all items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). Detailed following, both proposals are part of CMS’ “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule for Calendar Year 2005,” which deals with physician services. Comments on the proposal are due by Sept. 24. The final rule is scheduled to be published Nov. 1 and…
    Read More →: CMS Rolls Out Proposal for Drug Cuts, Face-to-Face Physician Exam

  • CMS Forms New Technology Council

    Baltimore CMS Administrator Mark McClellan has announced a new effort to ensure Medicare beneficiaries have timely access to new medical treatments and technologies. The new Council on Technology and Innovation (CTI) will include CMS specialists on clinical, coverage and payment issues. Part of an initiative mandated by the MMA, the council will address issues relating to the processes for Medicare coverage, coding and payment for new technologies and the exchange of information on new technologies between CMS and other entities charged with making similar considerations and decisions. The council, which replaces the current Medicare Technology Council, will be organized into two working groups. The Effective Innovation group will develop ways to improve the timeliness and efficiency of coverage, coding and payment processes, plus look for…
    Read More →: CMS Forms New Technology Council

  • CMS Closes Out DME Committee Applications

    Baltimore Following a July 2 deadline, CMS is going through nominations for potential members who will serve on the DME Program Advisory and Oversight Committee (PAOC). As mandated by the Medicare Modernization Act, the committee will advise the agency on quality and financial standards, data collection strategies and, ultimately, logistics behind the implementation of competitive bidding for DME. “We received a lot of [nominations] during the last hour — a huge stack of them,” a CMS official said. “It will take awhile to get through them all.” He added that at the time the total number of applications the agency received had not been tallied, and that a date had not yet been set for the final selection of committee members. “We’re just gathering names….
    Read More →: CMS Closes Out DME Committee Applications

  • CMS Slows Non-TCS-Compliant Claims

    Baltimore After announcing its intentions earlier this year, beginning July 6 CMS slowed processing of non-HIPAA-compliant claims — paying them no earlier than 27 days after receipt — to encourage use of the standardized transactions and code sets (TCS) format. According to CMS, about 87.5 percent of all Medicare providers are currently filing electronic claims in the TCS-compliant format. But, said a CMS official at a June 23 Home Health, Hospice and DME Open Door Forum, “that’s definitely not in the ballpark of 100 percent.” In a June 30 statement, CMS Administrator Mark Mcclellan said “for those still not in compliance, there is going to be a delay in getting their money. We are hoping this will motivate more filers to get into compliance soon.”…
    Read More →: CMS Slows Non-TCS-Compliant Claims

  • Medicare to Consider Obesity Coverage

    Washington After a three-year investigation, HHS has removed language stating obesity is not an illness from Medicare’s Coverage Issues Manual, paving the way for possible coverage of obesity treatment. In 2001, the Centers for Disease Control and Prevention asked CMS to review the issue of whether obesity should be considered an illness, but until now, the agency has denied coverage for obesity therapies. While the language change still does not define obesity as a disease, the revision does allow beneficiaries to request coverage for obesity-related treatments. “The critical issue is not the classification of obesity but whether particular items or services are reasonable and necessary,” according to CMS. “With this new policy, Medicare will be able to review scientific evidence in order to determine which…
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  • CMS May Ease Harris Country K0011 Reviews

    The government’s tight scrutiny of K0011 claims in Harris County (Houston), Texas, could ease, according to Steve McAdoo, associate regional administrator for the Division of Medicare Financial Management in CMS’ Dallas regional office. “We are in discussions with Palmetto GBA (Region C DMERC) to see whether or not we feel comfortable doing a modification in the level of review going on,” McAdoo said at a CMS June 23 Home Health, Hospice and DME Open Door Forum. “There could be some changes in the not-too-distant future.” A strict 100-percent review for all power wheelchair claims submitted in the Texas county has remained in effect since last September, when CMS and the OIG launched Operation Wheeler Dealer in response to a sharp rise in power wheelchair expenditures…
    Read More →: CMS May Ease Harris Country K0011 Reviews

  • NSC, CMS Propose Supplier Number Standards Clarification

    Columbia, S.C. According to both government officials and industry stake-holders, vague Medicare supplier standards are partly to blame for DME fraud. In response, earlier this year the National Supplier Clearinghouse Advisory Committee (NSCAC), which is made up of representatives from the four DMERC (durable medical equipment regional carrier) advisory councils, requested that the Centers for Medicare and Medicaid Services and the NSC draft written guidance for providers who must comply with the 21 Medicare supplier standards. At press time, the draft had been forwarded to NSCAC members, and representatives from both agencies would be “tweaking those clarifications if [committee members] have some substantive comments, which I’m sure they will,” said a CMS official. In late April, Leslie Aronovitz, director of health care program administration and…
    Read More →: NSC, CMS Propose Supplier Number Standards Clarification

  • New Power Wheelchair Guidance Expected by Year’s End

    Washington What are the thresholds clinicians use to determine who qualifies for power mobility equipment and who doesn’t? That question was the subject of a special CMS Open Door Forum held in mid-June as part of the agency’s new three-pronged approach — including coverage, standards and coding — to restructuring Medicare’s power wheelchair benefit. At the forum, CMS introduced the Interagency Wheelchair Work Group, which, over the coming months, will create a framework for clinical coverage policy for power wheelchairs. The government group is made up of clinical experts from across the Department of Health and Human Services, including the National Institutes of Health, along with physicians and physical and occupational therapists from the Department of Veterans Affairs and Department of Education. Sean Tunis, CMS’…
    Read More →: New Power Wheelchair Guidance Expected by Year’s End

  • Noteworthy

    ‘Homebound’ Demo to Launch in October CMS will launch a two-year, three-state demonstration project Oct. 4 to clarify what defines a “homebound” patient under Medicare’s home health benefit, the agency announced. The MMA-mandated project will determine if a broader definition of “homebound” will result in higher costs for Medicare. It will be limited to no more than 15,000 beneficiaries with permanent, disabling conditions requiring daily living assistance and skilled nursing for the rest of their lives. CMS has not yet announced in which three states the project will take place. Enteral Nutrition Reimbursements Excessive, OIG Says A recent report from the HHS OIG found that Medicare reimbursements for enteral nutrition formulas are excessive. Medicare’s reimbursement for Category I formulas exceeded median contract prices available from…
    Read More →: Noteworthy

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