Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee

60 - Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03-23) The CMS issues instructions for implementing and/or updating the DMEPOS fee schedule payment amounts on an annual basis (January), with quarterly updates as necessary (April, July and October). In addition, special instructions may be issued at any time if necessary for implementation of changes in the statute, regulations, or for other reasons. The DMEPOS fee schedule is provided to DME MACs, the Pricing, Data Analysis and Coding Contractor (PDAC), and A/B MACs (B) via CMS’ mainframe telecommunication system. Upon successful receipt of the updated file(s), MACs send notification of receipt via email to price_file_receipt@cms.hhs.gov stating the name of the file received and the entities for which they were received (e.g., MAC name and A/B MAC (A) or (HHH) number). A separate DMEPOS Fee Schedule file is released to A/B MACs (A) and (HHH), Railroad Retirement Board (RRB) and RRB’s Specialty MAC, Indian Health Service, and United Mine Workers. This fee schedule is also available on the CMS site (http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html) for other interested parties like the State Medicaid agencies and managed care organizations. The fee schedule for parenteral and enteral nutrition (PEN) is released to the PDAC and DME MACs in a separate file. All annual updates to fee schedules are to be implemented on January 1 for claims with dates of service on or after January 1. Effective February 28, 2022, national fee schedule amounts for new DMEPOS items and services that are added to the DMEPOS or PEN fee schedule files are established by CMS using the process summarized below and outlined in the regulations at 42 CFR 414.114 and 414.240. As explained in more detail in §60.3 below, MACs shall establish interim local fee schedule amounts for use in paying claims for new items and services billed using codes for miscellaneous items and services and for use in paying claims on an interim basis until the national fee schedule amounts are established. Process for Establishing National Fee Schedule Amounts – Effective February 28, 2022 If a preliminary determination is made by CMS that a new item or service without a fee schedule pricing history falls under a DMEPOS benefit category, CMS makes a preliminary payment determination for the item or service and posts the preliminary payment determination on the website www.CMS.gov approximately 2 weeks prior to a public meeting. After consideration of public consultation provided at the public meeting on the preliminary benefit category and payment determinations for the item or service, CMS posts final determinations on the website www.CMS.gov and implements the benefit category determinations and payment determinations for items and services through program instructions. Some determinations may be deferred to future cycles of the public consultation process if more time is needed to develop preliminary or final benefit category and payment determinations. Benefit category determinations are made using the public meeting process described above for an item or service that is the subject of a request for a HCPCS code set modification. Benefit category determinations are also made using the public meeting process in cases where a manufacturer for a new item or service is not requesting a HCPCS code set modification for the item or service, but requests CMS to determine whether the item or service falls under a DMEPOS benefit category. Benefit category determinations are also made using the public meeting process when CMS identifies a need to address whether an item or service falls under a DMEPOS benefit category.