CR9968 CURES Act Fee Schedule Adjustments

CMS issued Change Request (CR) 9968 to mass adjust all claims impacted by the extension of the transition to the fully adjusted Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) payment rates under Section 16007 of the 21st Century Cures Act. Noridian started these mass adjustments on 6/26/17 and completed them on 9/12/17.

On this page, view the below information.

Important Facts Regarding the Adjusted Claims

Noridian conducted adjustments for claims with dates of service 07/01/16-12/31/16 to correct the fee amounts for certain DME items furnished on/after 01/01/16, in areas that are not competitive bid areas due to CR9968 under the 21st Century Cures Act.

CR9968 states "Contractors shall create a one-time process to validate and adjust claims using the new 2016 DMEPOS fee schedule file when the following is true…" The following requirements are adapted from this change request, as directed by CMS.

  • HCPCS is one eligible for Cures Act adjustments as listed in Attachment A (beginning on page 10) of CR9968
  • Beneficiary did not reside in a current Round 1 or Round 2 competitive bid area
  • Beneficiary's address was in a current Round 1 or Round 2 competitive bid area, but DMEPOS item in question was grandfathered
  • Beneficiary's address was in a current Round 1 or Round 2 competitive bid area, but item was a wheelchair accessory and KY modifier was reported on claim

If a DMEPOS item was part of competitive bid and the beneficiary resided in a competitive bid area, no Cures Act adjustment will be done since the claim originally paid at the contractual price and no additional payment is allowed.

Noridian used the CMS approved RARC Code ‘N689' to identify claim adjustments with the following message.

Alert: This reversal is due to a retroactive rate change. N689 will be in the 2100. MOA segment of the ERA and in the claim header MIA/MOA section on the SPR.

There may be some claims adjusted that results in a potential overpayment. These may be due to patients in a SNF, HHH, etc. for the date of service on the claim. A supplier will receive an overpayment demand letter.

Claim Processing Education

Be aware of below claims processing items for CR9968 Cures Act Fee Schedule Adjustments.

  1. You may see the miscellaneous HCPCS E1399cc when an oxygen code was originally billed. Due to system limitations, HCPCS E1399 is being used when previous oxygen CMNs have been deleted and are no longer on file due to a new CMN superseding the previous CMN. HCPCS E1399 was used since it will not impact current or future oxygen claims. The cc modifier also signifies that the HCPCS was changed during processing.
  2. Rented Inexpensive and Routinely Purchased (IRP) items will not be adjusted when the first rental month occurred before 07/01/16. For rented IRP items, Medicare pays rentals up to the purchase price. Since the purchase price is established by the date of service from the first rental month, the purchase price will not change due to these adjustments, as the initial (first rental month) date of service does not fall into the timeframe for these adjustments, 7/1/2016-12/31/2016.
  3. Oxygen Concentrators: Some claims adjusted for the Cures Act adjustments were denied with code N370 (Billing exceeds rental months covered/approved by payer) rather than paying the last month of rental, i.e. only 35 rental payments were made. Noridian fixed claims when brought to our attention.
  4. Temporary Replacement of Beneficiary Owned Equipment (HCPCS K0462): Noridian reviews this code to assure that accurate payment has been made by suspending each claim for manual review. If you feel the claim was underpaid or denied in error, submit an appeal.
  5. Heated Humidifier (HCPCS E0562): This inexpensive and routinely purchased (IRP) item when billed as a rental, in some cases, did not process appropriately during the adjustment. Any IRP item billed as a rental will pay up to the fee schedule allowance. If the rental began prior to July 1, 2016, no additional payments will be made on claims for July 1, 2016, through December 31, 2016 dates of service because the fee schedule amount was already in effect. Noridian reviewed the claim adjustments to verify accurate payment.
  6. Wheelchair Accessories: To process wheelchair accessories claims adjusted by the Cures Act, in some cases, Noridian changed the submitted HCPCS to E1399 with a "cc" modifier (code change). This step is needed to pay the correct amount.

KE Modifier Reopenings

Noridian is accepting KE written reopening requests as outlined below for finalized claims with dates of service 01/01/16-12/31/16. Addition of KE modifiers cannot be completed during a telephone reopening.

As part of the fee schedule update for the 21st Century Cures Act, the KE modifier was added to the fee schedule for use on items bid under the initial Round 1 of Competitive Bidding but used with non-competitive bid base equipment.

See the HCPCS Applicable to KE Modifier listing [Excel].

Suppliers must submit a general written reopening request or a special project request to add the KE modifier to applicable claims.

KE Modifier Reopening Reminders

  • Noridian will add the KE modifier in the appropriate modifier location, based on other modifiers already present, allowing the claim to pay the additional fee schedule amount
  • When claim line requires purchase or rental modifier (NU, UE, RR), a monthly rental modifier (KH, KI, KJ) or a liability modifier (GA, GY, GZ), these modifiers will remain in one of the first four modifier locations

 

Last Updated Oct 22, 2018