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In a final rule issued on Tuesday, the Centers for Medicare and Medicaid Services has expanded access to certain durable medical equipment, such as continuous glucose monitors that increase diabetes treatment choices for people with Medicare. 

The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) final rule establishes methodologies for adjusting the Medicare DMEPOS fee schedule amounts, as well as procedures for making benefit category and payment determinations for new items and services that are DMEPOS, therapeutic shoes and inserts, surgical dressings, or splints, casts, and other devices used for reductions of fractures and dislocations under Medicare Part B.

All of this, said CMS, is an effort to prevent delays in the coverage of these items and services.

The final rule also classifies adjunctive continuous glucose monitors as durable medical equipment (DME) under Medicare Part B, and finalizes certain DME payment provisions that were included in two interim final rules.

FEE SCHEDULE ADJUSTMENTS

The rule establishes the methodologies for adjusting the fee schedule payment amounts for DMEPOS items furnished in non-competitive bidding areas (non-CBAs) on or after the effective date of the rule, or the date immediately following the duration of the COVID-19 public health emergency – whichever is later – using the information from the DMEPOS Competitive Bidding Program (CBP).

CMS will continue paying suppliers the 50/50 blend of adjusted and unadjusted fee schedule rates for furnishing items and services in rural and non-contiguous areas. The rates, said CMS, were informed by stakeholder input. They’ve highlighted certain higher costs and greater travel distances in certain non-CBAs compared to CBAs; the unique logistical challenges and costs of furnishing items to beneficiaries in the non-contiguous areas; the significantly lower volume of items furnished in these areas vs. CBAs; and concerns about financial incentives for suppliers in surrounding urban areas to continue including outlying rural areas in their service areas. 

CMS said it will continue to monitor payments in rural and non-contiguous areas and all non-CBAs, as well as health outcomes, assignment rates, and other information. The agency may also consider payment methodologies toward DMEPOS items and services furnished in rural and non-contiguous areas and non-CBAs in the context of any future changes to the DMEPOS CBP.

For contiguous, non-rural areas, CMS will be paying suppliers 100% of the adjusted fee schedule rates using information from the DMEPOS CBP. For the former CBAs, CMS will be paying the single payment amounts (SPAs) established during DMEPOS CBP updated by an inflation adjustment factor on an annual basis.

DME INTERIM PRICING IN THE CARES ACT

The rule also revises the fee schedule amounts for certain DMEPOS items and services furnished during the PHE using a blend of fee schedule amounts adjusted using information from the DMEPOS CBP and unadjusted fee schedule amounts.

Section 3712(a) of the CARES Act mandates that the fee schedule amounts for certain items furnished in rural and non-contiguous non-competitive bidding areas be based on a 50/50 blend of adjusted and unadjusted fee schedule amounts through the duration of the PHE, and section 3712(b) of the CARES Act mandates that the fee schedule amounts for these same items furnished in all other non-competitive bidding areas be based on a 75/25 blend of adjusted and unadjusted fee schedule amounts through the duration of the PHE.

BENEFIT CATEGORY FOR PAYMENT DETERMINATIONS

Additionally, the rule establishes procedures for making benefit category determinations and payment determinations for new DMEPOS, therapeutic shoes and inserts, surgical dressings, or splints, casts and other devices used for reductions of fractures and dislocations under Medicare Part B that permit public consultation through public meetings. 

CMS has established procedures for coding and payment determinations for new DMEPOS under Medicare Part B that permit public consultation in a manner consistent with the procedures established for implementing coding modifications for ICD-9-CM – which has since been replaced with ICD-10-CM as of October 1, 2015. CMS started using these procedures for Healthcare Common Procedure Coding System (HCPCS) Level II code requests for items and services other than DME in 2005.

CONTINUOUS GLUCOSE MONITORS UNDER MEDICARE PART B

The final rule classifies adjunctive continuous glucose monitors (CGMs) under the Medicare Part B benefit for DME.
 
But CMS is not finalizing the proposed categories of supplies and accessories and fee schedule amounts for three types of CGM systems. After considering public comments, CMS said it doesn’t believe it’s necessary to further stratify the types of CGMs beyond the two categories of non-adjunctive and adjunctive CGMs.
 

Twitter: @JELagasse
Email the writer: [email protected]



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