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From The Desk Of Ronda Buhrmester: IFR Updates

The latest Interim Final Rule (IFR) CMS-5531 that was released on April 30th provided more information for the DME supplier community. There are three sections that I will be covering within this article.

To start, with the CARES Act and the CMS-5531 reimbursement rates within the rural and non-rural zip codes.

  • Rural and contiguous areas: The 50/50 blend will extend the reimbursement rates for beyond 2020, for the duration of the COVID-19 Public Health Emergency (PHE).
  • Former Competitively Bid Areas: The single payment rates (SPA) will remain the same (unchanged).
  • Non-Rural and noncontiguous areas will get the 75/25 blended rate. That is 75% of the regional competitive bid rates and 25% of the 2015 unadjusted rates through the PHE.
  • Temporary elimination of 2 percent Medicare sequester reduction that went into effect in 2013. This relief will be effective for May 1-Dec. 31, 2020.

For non-rural and noncontiguous areas, the rates will be retroactive as of March 6, 2020, through the duration of emergency period. The adjusted (blended) rates only apply to HCPCS codes that are considered part of the former CB product categories.

Some of our members have already informed us of the new non-rural blended rates being reimbursed on claims with dates of service April 2020. 

I have a couple of resources for you for checking zip codes and new (increased rates).

This first link is found on the VGM Government website that allows you to select a state. It is color coded showing CBA, Rural, and Non-rural areas. Check it out, I have to say it’s pretty cool.


This second link is to the CMS website for the excel spreadsheet for the rural and non-rural rates from the CARES Act.  


The next step is for CMS to provide instruction to the DME MACs (CGS & Noridian) for processing instructions on the adjustments for the retroactive date. This instruction should be released in the form of an MLN article. The adjustments should be processed automatically as a mass adjustment. 

I have homework for you, please check your ERNs for the increased rates. If you are getting payment on the increased rates, please share with me, my contact information is at the end of the article.

Secondly, the latest IFR CMS-5531 discusses the applicability of “Reasonable and Necessary” requirements for covered items and services. The language states the following, “Except as expressly permitted by statute, we remind physicians, practitioners and suppliers that most items and services must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member to be paid under Part A or Part B of Title XVIII. Physicians, practitioners, and suppliers are required to continue documenting the medical necessity for all services. Accordingly, the medical record must be sufficient to support payment for the services billed (that is, the services were actually provided, were provided at the level billed, and were medically necessary).”

What does this mean for DME suppliers? This means that the item being ordered needs to have the coverage criteria met. Please be sure to follow the medical policy as best you can. If for some reason this is not possible, document exactly what is occurring and why for your records and for reference.  All the policies must have coverage criteria met, with some exceptions to respiratory and few others listed in the next section.

Thirdly, the IFR language reviews the enforcement discretion of clinical Indications for additional LCDs. The language states “We are finalizing on an interim basis that we will not enforce the clinical indications for therapeutic continuous glucose monitors in LCDs. For example, we will not enforce the current clinical indications restricting the type of diabetes that a beneficiary must have or relating to the demonstrated need for frequent blood glucose testing in order to permit COVID-19 infected patients with diabetes to receive a Medicare covered therapeutic continuous glucose monitor. This discretion is intended to permit COVID-19 patients to more closely monitor their glucose levels given that they are at risk for unpredictable impacts of the infection on their glucose levels and health. The use of therapeutic continuous glucose monitors may allow patients to proactively treat their diabetes and prevent the need for hospital-based diabetic care. Practitioners will also have greater flexibility to allow more of their diabetic patients to better monitor their glucose and adjust insulin doses from home by using a therapeutic continuous glucose monitor. This enforcement discretion will only apply during the PHE for the COVID-19 pandemic. “

Also, CMS has updated the FAQ on Medicare FFS billing.  It appears this is being updated regularly. Here is one question and answer that needs pointed out to our members.

Question: Are there other NCDs/LCDs whose clinical indications will not be enforced during the PHE?

Answer: Yes, CMS-1744-IFC, Section U includes respiratory, anticoagulation management and infusion pump policies. Some NCDs and LCDs are specifically identified in the IFC. In addition to that list, we have identified LCDs for nebulizers and high frequency chest wall oscillation and will continue to update the list in these FAQs if we identify other NCDs or LCDs that fall within the types established in CMS-1744-IFC. Questions may be directed to your Medicare Administrative Contractor regarding whether additional NCDs or LCDs should be considered.

• NCD 240.2 Home Oxygen

• NCD 240.4 Continuous Positive Airway Pressure for Obstructive Sleep Apnea

• LCD L33800 Respiratory Assist Devices (ventilators for home use)

• NCD 240.5 Intrapulmonary Percussive Ventilator

• LCD L33797 Oxygen and Oxygen Equipment (for home use)

• NCD 190.11 Home Prothrombin Time/International Normalized Ratio (PT/INR)

• LCD L33785 High frequency chest wall oscillation

• LCD L33370 Nebulizers

• LCD 35434 Oximetry services

New: 4/23/20

Here is the link to the FAQ https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

What does this mean for DME suppliers? Be care with the CGMs! Once a patient is using a CGM, they cannot revert to standard blood glucose monitor once the CGM is being reimbursed by Medicare FFS. I highly encourage this policy to be followed.

As for the other policies related to the respiratory equipment, I recommend that you all follow the LCD/NCD as close as possible. It’s in your best interest. Each referral/patientamnd may need to be treated on a case by case basis. If you can only get an order for oxygen, then set the patient up, take care of the patient. But also monitor that patient to know when they no longer need the equipment.

Lastly, as I have received many questions related to the CMS-484 oxygen CMN, we do not have any direction yet. It’s a claim processing issue that is being worked on by CMS and the DME MACs. Once we know more information, we will be sure to share it with our members.

Please reach out to me with questions or to setup a call to discuss your questions. I am here to help make sure you all get paid, paid correctly, and most importantly keep your money!  I want to hear from you.

Thank you all for your support!

Ronda Buhrmester

[email protected]