03/16/2021

Juris B DME MAC Posts Instructions for Reprocessing Claims Due to CMS Fee Schedule Errors

 

On December 11, 2020, CMS released the 2021 Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule amounts. The DMEPOS and Parenteral and Enteral Nutrition (PEN) public use files contain fee schedules for certain items that were adjusted based on information from the Medicare DMEPOS Competitive Bidding Program in accordance with Sections 1834(a)(1)(F) and 1842(s)(3)(B) of the Act. CMS identified errors in the fee schedule amounts for some items and has released revised public use fee schedule files. A list of 919 Healthcare Common Procedure Coding System (HCPCS) code and modifier combinations affected by the revisions is included as a separate public use file under the link below. The revised January 2021 public use files are available online: January 2021 Public Use Files.

Claims submitted before January 26, 2021 with dates of service on or after January 1, 2021 may have been processed and paid using the incorrect fee schedule amounts. Most of the corrections to the fee schedule amounts were minor, resulting in the application of a missing update factor and an increase in the 2021 fee schedule amount of less than 1%.

However, in approximately 8% of the cases, the corrections were significant. CMS identified multiple calculation errors, and correction of those errors has resulted in changes that range from a 2021 fee schedule amount decrease of 30% to a 2021 fee schedule amount increase of 57%. Most of these significant fee schedule corrections are for claims that included a KE modifier, with the greatest fee schedule amount increases in the non-contiguous areas of the country.

Suppliers may request that the DME MAC reprocess and adjust incorrectly paid claims for these HCPCS code/modifier combinations by providing their Provider Transaction Access Number (PTAN) to the DME MAC. If the supplier makes this request, then all the supplier’s claims affected by the erroneous fee schedule amounts (both overpayments and underpayments) will be reprocessed and adjusted.

Adjustments should only be requested when all the following apply:

• Claim was submitted before January 26, 2021
• Date of service is on or after January 1, 2021
• HCPCS/modifier combinations found in the separate file located online: January 2021 Public Use Files

How to request a reopening for all HCPCS code/modifier combinations:

• If there are multiple claims that need to be adjusted for a single PTAN, one Reopening Request Form is sufficient.
• The “Comments” section of the form must include a note that the reopening request is a result of “Corrections to the 2021 DMEPOS Fee Schedule Amounts for a HCPCS code and modifier combination listed in the CMS January 2021 Public Use Files”.

How to request a reopening of specific claims:

• For multiple claims, submit the Multiple Claim Beneficiary Form
• For a single claim, submit the Reopening Request Form
• Contact the Jurisdiction B Telephone Reopenings line at 844.240.7490

There are three ways the to submit forms:

1. The myCGS Web Portal
2. Fax a Jurisdiction B reopening with an underpayment to 615.660.5978. Fax a reopening with an overpayment to 615.782.4508.
3. Mail to the following address:
   
   CGS DME MAC Jurisdiction B
   ATTN: Reopening Department
   PO Box 20007
   Nashville, TN 37202