This should not be a guessing game, nor should it be a mystery. Knowing what your reimbursement should be for a service is an important tool in planning treatments and in checking your Explanation of Benefits (EOBs). This is the case with evaluation and management services, procedures, and durable medical equipment, including both surgical dressings and compression garments.
DMEPOS Fee Schedule
Anyone who is dispensing durable medical equipment (DME) and / or prosthetics / orthotics (POS) should know that the Centers for Medicare and Medicaid Services (CMS) publish a DMEPOS fee schedule quarterly.
When visiting this site, you will find links to four different fee schedules for each previous calendar year including however many of the current year’s fee schedules have been posted to date. The number of current year fee schedules available varies based on the how many quarters of the current year have passed.
Navigating the DMEPOS Fee Schedule Site
For each calendar year, the link for the first quarter fee schedule is labeled, “DMEXX-A” with the “XX” representing the last two digits of the calendar year. The final letter changes to “B” for the 2nd quarter, “C” for the third quarter, and “D” for the fourth quarter. For example, the link for the current fee schedule, effective October, 2019, is “DME19 – D”. Once the link for the desired quarter is clicked, you are prompted to download a zip file which contains multiple files.
Finding the Part We Care About
In viewing the multiple files within this zip file, the one most of us are interested in is the one titled, “DMEPOS_month.xlsx”. In that example, “month” will be filled in with the month that the fee schedule became effective. For example, the title of the current fee schedule is “DMEPOS_OCT.xlsx”. Once this is opened, all of the HCPCS codes are listed in the left hand column, and the fee schedule for each state corresponding to each code is listed from left to right in alphabetical order by state.
Next month we will break down the details of this fee schedule including an explanation of the “ceiling” and the “floor” values.
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance for ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.
About the Author
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPCDr. Lehrman is in private practice in Fort Collins, CO and operates Lehrman Consulting, LLC. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. He is a Fellow of the American Academy of Podiatric Practice Management and an Expert Panelist on Codingline. In his role as a Consultant to the APMA Health Policy and Practice Department, Dr. Lehrman serves as an advisor to the APMA Coding Committee and the APMA MACRA Task Force. Dr. Lehrman sits on the board of directors of both the American Professional Wound Care Association and the American Society of Podiatric Surgeons. He is also on the editorial advisory board of the journal WOUNDS.