CMS Wants to Streamline DMEPOS Reimbursement, Boost Rural Pay

A new proposed rule from CMS is seeking to streamline how the agency determines if durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) qualify for Medicare reimbursement and coverage.

The proposed rule for the Medicare DMEPOS fee schedule released yesterday by CMS would codify changes to coding, coverage, and payment for new items. The changes made through sub-regulatory guidance that would be finalized in this rule include more frequent coding cycles, including timeframes for application submission and final decisions.

The changes implemented last year have reduced the process of making Medicare benefit classifications, pricing determinations, and billing code establishment from an average of 18 months to complete to just six months for some items, CMS stated in the proposed rule.

By finalizing the changes and making these actions more transparent, CMS intends to permanently streamline the process, enabling benefit classification and pricing decisions to happen on the same day the billing codes used for payment of new items take effect.

If finalized, the new process would be a “win-win for patients and innovators alike,” CMS Administrator Seema Verma said in an announcement.

“With the policies outlined in this proposed rule, innovators have a much more predictable path to understanding the kinds of products that Medicare will pay for,” added Verma “For manufacturers, bringing a new product to market will mean they can get a Medicare payment amount and billing code right off the bat, resulting in quicker access for Medicare beneficiaries to the latest technological advances and the most, cutting-edge devices available.”

Verma also highlighted that the proposed would expand Medicare reimbursement and coverage for continuous glucose monitors and external infusion pumps.

Currently, CMS only covers therapeutic continuous glucose monitors or those approved by the Food and Drug Administration (FDA) for use in making diabetes treatment decisions, such as changing a patient’s diet or insulin dosage based solely on the readings of the monitor.

The proposed rule would classify all continuous glucose monitors as DME and establish payment rates for the items and related supplies and accessories and enable monitors that are not approved for use in diabetes treatment decision-making to be used to alert beneficiaries about potentially dangerous glucose levels while they sleep.

The rule would also expand the classification of external infusion pumps as DME in cases where assistance from a skilled home infusion therapy supplier is necessary for safe infusion in the home.

Expanding coverage for the devices would help patients manage their diabetes by providing critical information on blood glucose levels and expand patient access to more therapy choices at home, CMS stated. The proposed rule would also codify higher Medicare reimbursement amounts to suppliers for DMEPOS items and services furnished in rural and non-contiguous areas. The agency included the proposal after stakeholders commented on the higher costs for furnishing items and services in these areas because of greater travel distances and the unique logistical challenges of getting the items to beneficiaries in the regions.

Under the proposal, CMS would also pay 100 percent of the adjustment amount under Medicare DMEPOS fee schedule for all areas in non-rural, non-competitive bidding areas in the contiguous US.

If finalized, the proposed rule would apply to items furnished on or after April 1, 2021, or the date immediately following the duration of the emergency period.