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Policy No: 118

Originally Created:  08/01/2014

Section: Administrative

Last Reviewed:  05/01/2018

Last Revised:  05/01/2018

Approved: 05/17/2018

Effective: 10/01/2018

This policy applies only to physicians and other qualified healthcare professionals.

Definitions

Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) are classified by the Centers for Medicare & Medicaid (CMS) into 10 categories below:

 
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
PO Prosthetics & Orthotics
SD Surgical Dressings
SU Supplies
TE Transcutaneous Electrical Nerve Stimulators
TS Therapeutic Shoes
IL Intra Ocular Lens
SC Spliting and Casting

 

Policy statement

Medicare Advantage reimbursement of DMEPOS codes will be at the lesser of billed charges or 100% of current DMEPOS fee schedule amount published by CMS.

Parenteral and Enteral Nutrition (PEN) codes will be reimbursed at the lesser of billed charges or 80% of the current DMEPOS fee schedule published by CMS.

Our health plan reserves the right to set a fee schedule amount for a DMEPOS code which is different from the amount published in the CMS DMEPOS fee schedule. For codes which do not have CMS fees, we may assign a payment rate that is a fee schedule amount or a percentage of billed charges.

References

None

Cross References

Medicare-Based Fee Effective Dates

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.