Record Layout for DMEPOS Fee Schedule

60.1 - Record Layout for DMEPOS Fee Schedule (Rev. 12991; Issued: 12-13-24; Effective: 01-01-25; Implementation: 01-06-25) Sort Sequence: Category, HCPCS, 1st Modifier, 2nd Modifier State Field Name Pic Position Comment Year X(4) 1 - 4 Applicable Update Year HCPCS Code X(5) 5 - 9 All current year active and deleted codes subject to DMEPOS floors and ceilings 1st Modifier X(2) 10 - 11 2nd Modifier X(2) 12 - 13 Jurisdiction X 14 D = DME MAC Jurisdiction L = Local A/B MAC (B) jurisdiction J = Joint DME MAC/A/B MAC (B) jurisdiction Category X(2) 15 - 16 IN = Inexpensive/Routinely Purchased FS = Frequently Serviced CR = Capped Rental OX = Oxygen & Oxygen Equipment OS = Ostomy, Tracheostomy & Urologicals SD = Surgical Dressings PO = Prosthetics & Orthotics SU = Supplies TE = TENS TS = Therapeutic Shoes SC = Splints and Casts IL = Intraocular Lenses LC = Lymphedema Compression Treatment Items LT = Labor Rate HCPCS Action X 17 Indicates active/delete status in HCPCS file A = Active Code D = Deleted Code, price provided for grace period processing only Region X(2) 18 - 19 This amount is not used for pricing claims. It is on file for informational purposes. 00 = For all non Prosthetic and Orthotic Services 01 - 10 = For Prosthetic and Orthotic Services only. This field denotes the applicable regional fee schedule. State X(2) 20 - 21 Original Base Fee 9(5)V99 22 - 28 This amount is not used for pricing claims. It is on file for informational purposes. For capped rental services, this amount represents the base fee after adjustments for rebasing and statewide conversions. The base year for E0607 and L8603 is 1995. Since pricing amounts for E1405 and E1406 are developed by summing pricing amounts from source codes, they do not have a true base fee. For these codes, this field will be filled with zeros. Beginning January 1, 2016, this field will include the Competitive Bidding Rural Fee Amount for specific HCPCS codes. A new indicator field (RURAL FEE INDICATOR) shall be populated with a value of “R” when the Rural Fee is present in this field. Ceiling 9(5)V99 29 - 35 This amount is not used for pricing claims. It is on file for informational purposes and could be integrated into other processes (i.e., IR review, validation, inquiries). NOTE: Since E0607 is priced via national IR, it is not priced using floors and ceilings. For E0607, this field will be filled with zeros. Since pricing amounts for E1405 and E1406 are developed by summing pricing amounts from source codes, they are not subject to ceilings and floors. Since non-mail order (no-KL) codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259 are priced using National Mail order single payment amounts, they are not subject to ceilings and floors. Splints, casts and intraocular lenses are national fee schedule amounts not subject to ceilings. For these codes, this field will be filled with zeros. Beginning January 1, 2016, this field will also be filled with zeros for codes whose fees are adjusted using DMEPOS competitive bid information. Labor rates and lymphedema compression treatment items are not subject to ceilings. Floor 9(5)V99 36 - 42 This amount is not used for pricing claims. It is on file for informational purposes and could be integrated into other processes (i.e., IR review, validation, inquiries). NOTE: Since E0607 is priced via national IR, it is not priced using floors and ceilings. For E0607, this field will be filled with zeros. Since pricing amounts for E1405 and E1406 are developed by summing pricing amounts from source codes, they are not subject to ceilings and floors. Since non-mail order (no-KL) codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259 are priced using National Mail order single payment amounts, they are not subject to ceilings and floors. Splints, casts and intraocular lenses are national fee schedule amounts not subject to floors. For these codes, this field will be filled with zeros. Beginning January 1, 2016, this field will also be filled with zeros for codes whose fees are adjusted using DMEPOS competitive bid information. Labor rates and lymphedema compression treatment items are not subject to floors. Updated Fee Schedule Amount 9(5)V99 43 - 49 Amount used for pricing. Filler X 50 Set to spaces Pricing Change Indicator X 51 0 = No change to the updated fee schedule amount since previous release. 1 = A change has occurred to the updated fee schedule amount since the previous release. Rural Fee Indicator X(01) R = Rural Fee is present in the Original Base Fee field Filler X(8) 53 - 60 Set to spaces