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Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule Table
The DMEPOS fee schedule contains fee schedule amounts, floors, and ceilings for each procedure code subject to the DMEPOS fee schedule payment methodology. Although these fee schedule amounts are contained in a single table, their calculations have been mandated by three separate payment methodologies: DME, prosthetic and orthotic, and surgical dressings. For further information on these payment methodologies and their policy histories, please refer to Background below.
Column Headings and Status Codes
HCPCS CODE
All current year active and deleted codes subject to DMEPOS floors and ceilings.
MODIFIER
NU--Purchased, New
RR--Rented
UE--Purchased, Used
KM-Replacement of Facial Prosthesis including new
impression/moulage
KN-Replacement of Facial Prosthesis using previous master mold
AU--Urological, ostomy or trach item
JURISDICTION
D--DMERC jurisdiction
L--Local Part B Carrier jurisdiction
J--Joint DMERC/Local Carrier jurisdiction
CATEGORY
IN--Inexpensive and Other Routinely Purchased Items
FS--Frequently Serviced Items
CR--Capped Rental Items
OX--Oxygen and Oxygen Equipment
OS--Ostomy, Tracheostomy & Urological Items
SD--Surgical Dressings
PO--Prosthetics & Orthotics
SU--Supplies
TE--Transcutaneous Electrical Nerve Stimulators
CEILING
Maximum fee schedule amount.
Please note that since E0607 is priced via national Inherent Reasonableness, it is not priced using floors and ceilings. For E0607, this field will be filled with zeros. Since pricing amounts for E1405 and E1406 were developed by summing pricing amounts from source codes, they are not subject to ceilings and floors.
FLOOR
Minimum fee schedule amount.
Please note that since E0607 is priced via national Inherent Reasonableness, it is not priced using floors and ceilings. For E0607, this field will be filled with zeros. Since pricing amounts for E1405 and E1406 were developed by summing pricing amounts from source codes, they are not subject to ceilings and floors.
Background:
Medicare payment for durable medical equipment (DME), prosthetics and orthotics (P&O), and surgical dressings is equal to 80 percent of the lower of either the actual charge for the item or the fee schedule amount calculated for the item, less any unmet deductible. The beneficiary is responsible for 20 percent of the lower of either the actual charge for the item or the fee schedule amount calculated for the item, plus any unmet deductible. The DME and P&O fee schedule payment methodology is mandated by section 4062 of the Omnibus Budget Reconciliation Act (OBRA) of 1987, which added section 1834(a) to the Social Security Act. OBRA of 1990 added a separate subsection, 1834(h), for P&O. The DME and P&O fee schedules were implemented on January 1, 1989 with the exception of the oxygen fee schedules, which were implemented on June 1, 1989. Section 13544 of OBRA of 1993, which added section 1834(i) to the Social Security Act, mandates a fee schedule for surgical dressings; the surgical dressing fee schedule was implemented on January 1, 1994. Section 4315 of the Balanced Budget Act of 1997, which added section 1842(s) to the Social Security Act, authorizes a fee schedule for parenteral and enteral nutrition (PEN); the PEN fee schedule was implemented on January 1, 2002.
DME Fee Schedule Payment Methodology
The DME fee schedules are calculated for the following DME payment classes:
INEXPENSIVE AND OTHER ROUTINELY PURCHASED ITEMS (Section 1834(a)(2))
These items have a purchase price of $150 or less, or are generally purchased 75 percent of the time or more, or are accessories used in conjunction with certain nebulizers, aspirators, and ventilators. If covered, these items can be purchased new or used and
can be rented; however, total payments cannot exceed the purchase new fee for the item.
FREQUENTLY SERVICED ITEMS (Section 1834(a)(3))
These items require frequent and substantial servicing. Examples of such items are provided in section 1834(a)(3)(A). If covered, these items can be rented as long as they are medically necessary.
OXYGEN AND OXYGEN EQUIPMENT (Section 1834(a)(5))
Medicare payment for oxygen and oxygen equipment is made on a monthly basis. One bundled monthly payment amount is made for all covered stationary equipment, stationary and portable contents, and all accessories used in conjunction with the oxygen equipment. If the beneficiary owns her equipment and oxygen contents are covered, a monthly payment is made for oxygen contents only. An additional monthly payment may be made for those beneficiaries who require portable oxygen. If the beneficiary owns their portable equipment, then a monthly payment may be made for portable contents only.
OTHER COVERED ITEMS (OTHER THAN DME) (Section 1834(a)(6))
These are supplies that are necessary for the effective use of DME. Medicare payment is made for the purchase of these supplies, if covered.
CAPPED RENTAL ITEMS (Section 1834(a)(7))
These are items of DME which do not fall under any of the other DME payment categories. They are generally expensive items which have historically been routinely rented. In general, Medicare pays for the rental of these items, when covered, for a period of continuous use not to exceed 15 months. The beneficiary can decide to purchase the item in the tenth month of rental. In this case, Medicare rental payments are
capped out@ at 13 months instead of 15 months. Power wheelchairs can be purchased in the first month of use.
The fee schedule amount is calculated based on 10 percent of the base year purchase price increased by the covered item update. This is the fee schedule amount for months 1 thru 3. Beginning with the fourth month, the fee schedule amount is equal to 75 percent of the fee schedule amount paid in the first three rental months. The purchase fee schedule amount for power wheelchairs is equal to the rental fee (for months 1 thru 3) multiplied by ten.
Fee schedule amounts are not calculated for customized DME:
CERTAIN CUSTOMIZED ITEMS (Section 1834(a)(4))
If covered, Medicare payment is made in a lump-sum amount for the purchase of the item; this payment amount is based on the carrier's individual consideration for that item.
National Ceiling And Floor Limits for DME and Surgical Dressings
The fee schedule amounts for DME and surgical dressings are calculated on a statewide basis and are limited by national ceilings and floors. The fee schedule ceiling is equal to the median or mid-point of the statewide fee schedule amounts. The fee schedule floor is equal to 85 percent of the median of the statewide fee schedule amounts.
Covered Item Updates for DME and Surgical Dressings
The fee schedules for DME and surgical dressings are updated annually by a covered item update established through legislation. The covered item updates for 1990 through 2002 are:
1989 Initial Year of Fee Schedules
1990 0.0 percent
1991 3.7 percent
1992 3.7 percent
1993 3.1 percent
1994 3.0 percent
1995 2.5 percent
1996 3.0 percent
1997 2.8 percent
1998 0.0 percent
1999 0.0 percent
2000 0.0 percent
2001 3.7 percent (does not apply to oxygen and oxygen equipment or surgical dressings which received a 0.0 percent update for 2001)
2002 0.0 percent
2003 1.1 percent (does not apply to oxygen and oxygen equipment which received a 0.0 percent update for 2003)
2004 2.1 percent (does not apply to oxygen and oxygen equipment which received a 0.0 percent update for 2004)
P&O Fee Schedule Payment Methodology
Regional purchase (new) fee schedule amounts are calculated for P&O (section 1834(h)). The P&O payment class includes: ostomy, tracheostomy, and urological supplies; orthotics; prosthetics; prosthetic devices; and certain vision services. The regional fees are equal to the weighted average of the statewide fees in each HCFA Region.
* Per OBRA of 1993, effective January 1, 1994, the purchase (new) fee schedule amounts for ostomy, tracheostomy, and urological supplies are calculated using the same methodology as the purchase (new) fee schedule amounts for inexpensive or routinely purchased items of DME. As a result, these items are not subject to regional fee schedules. A fee schedule ceiling and floor, based on the median and 85 percent of the median, respectively, of the local fee schedule amounts are calculated for each item. The fee schedule amounts for these items are updated by the DME/surgical dressing covered item updates.
National Ceiling And Floor Limits for P&O
The P&O regional fee schedule amounts are limited by a ceiling (120% of the average of the regional statewide fees) and a floor (90% of the average of the regional statewide fees).
Covered Item Updates for P&O
The fee schedules for P&O are updated annually by a covered item update established through legislation. The covered item updates for 1990 through
2004 are:
1989 Initial Year of Fee Schedules
1990 0.0 percent
1991 0.0 percent
1992 4.7 percent
1993 3.1 percent
1994 0.0 percent
1995 0.0 percent
1996 3.0 percent
1997 2.8 percent
1998 1.0 percent
1999 1.0 percent
1999 1.0 percent
2000 1.0 percent
2001 3.7 percent
2002 1.0 percent
2003 1.1 percent
2004 2.1 Percent
PEN Fee Schedule Payment Methodology
The payment methodology for PEN changed effective January 1, 2002. Section 4315 of the Balanced Budget Act of 1997, which added section 1842(s) to the Social Security Act, authorizes a fee schedule for PEN. This fee schedule is a national fee schedule (i.e., no variation from state to state).
Covered Item Updates for PEN
2002 Initial Year
2003 1.1 percent
2004 2.1 percent
STATES:
ALABAMA FEE SCHEDULE AMOUNT
ARKANSAS FEE SCHEDULE AMOUNT
ARIZONA FEE SCHEDULE AMOUNT
CALIFORNIA FEE SCHEDULE AMOUNT
COLORADO FEE SCHEDULE AMOUNT
CONNECTICUT FEE SCHEDULE AMOUNT
DISTRICT OF COLUMBIA FEE SCHEDULE AMOUNT
DELAWARE FEE SCHEDULE AMOUNT
FLORIDA FEE SCHEDULE AMOUNT
GEORGIA FEE SCHEDULE AMOUNT
IOWA FEE SCHEDULE AMOUNT
IDAHO FEE SCHEDULE AMOUNT
ILLINOIS FEE SCHEDULE AMOUNT
INDIANA FEE SCHEDULE AMOUNT
KANSAS FEE SCHEDULE AMOUNT
KENTUCKY FEE SCHEDULE AMOUNT
LOUISIANA FEE SCHEDULE AMOUNT
MASSACHUSETTS FEE SCHEDULE AMOUNT
MARYLAND FEE SCHEDULE AMOUNT
MAINE FEE SCHEDULE AMOUNT
MICHIGAN FEE SCHEDULE AMOUNT
MINNESOTA FEE SCHEDULE AMOUNT
MISSOURI FEE SCHEDULE AMOUNT
MISSISSIPPI FEE SCHEDULE AMOUNT
MONTANA FEE SCHEDULE AMOUNT
NORTH CAROLINA FEE SCHEDULE AMOUNT
NORTH DAKOTA FEE SCHEDULE AMOUNT
NEBRASKA FEE SCHEDULE AMOUNT
NEW HAMPSHIRE FEE SCHEDULE AMOUNT
NEW JERSEY FEE SCHEDULE AMOUNT
NEW MEXICO FEE SCHEDULE AMOUNT
NEVADA FEE SCHEDULE AMOUNT
NEW YORK FEE SCHEDULE AMOUNT
OHIO FEE SCHEDULE AMOUNT
OKLAHOMA FEE SCHEDULE AMOUNT
OREGON FEE SCHEDULE AMOUNT
PENNSYLVANIA FEE SCHEDULE AMOUNT
RHODE ISLAND FEE SCHEDULE AMOUNT
SOUTH CAROLINA FEE SCHEDULE AMOUNT
SOUTH DAKOTA FEE SCHEDULE AMOUNT
TENNESSEE FEE SCHEDULE AMOUNT
TEXAS FEE SCHEDULE AMOUNT
UTAH FEE SCHEDULE AMOUNT
VIRGINIA FEE SCHEDULE AMOUNT
VERMONT FEE SCHEDULE AMOUNT
WASHINGTON FEE SCHEDULE AMOUNT
WISCONSIN FEE SCHEDULE AMOUNT
WEST VIRGINIA FEE SCHEDULE AMOUNT
WYOMING FEE SCHEDULE AMOUNT
ALASKA FEE SCHEDULE AMOUNT
Fee schedule amounts for non-continental areas are not subject to the ceilings and floors.
HAWAII FEE SCHEDULE AMOUNT
Fee schedule amounts for non-continental areas are not subject to the ceilings and floors.
PUERTO RICO FEE SCHEDULE AMT
Fee schedule amounts for non-continental areas are not subject to the ceilings and floors.
VIRGIN ISLANDS FEE SCHEDULE AMT
Fee schedule amounts for non-continental areas are not subject to the ceilings and floors.
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