Reimbursement Issues


Medicare Sequestration Suspension Extended Through the Remainder of 2021

The 2% sequestration-based reduction in Medicare reimbursement has been suspended for the remainder of the year. The sequestration suspension technically expired on March 31, 2021 but there was bi-partisan support to continue suspension of sequestration to reduce the burden on providers so they can focus on delivering necessary healthcare services. As part of the anticipated extension CMS has instructed its contractors, including the DME MACs to hold claims with a date of service on or after April 1, 2021. With the extension now in place the DME MACs will release any previously held claims with dates of service on or after April 1, and will reprocess any claims paid with the reduction applied.

Medicare to Allow Nurse Practitioners and Physician Assistants to Certify the Medical Need for Diabetic Shoes in Limited Circumstances

CMS and the DME MACs have announced two separate pathways that expand the ability of NPs and PAs to certify the medical need for diabetic shoes provided to Medicare beneficiaries. For more information read  the full announcement.

2021 Medicare Fee Schedule Update

The Centers for Medicare and Medicaid Services (CMS) has released the 2021 Medicare DMEPOS fee schedule which will be effective for Medicare claims with a date of service on or after January 1, 2021.  The 2021 Medicare fee schedule will be increased by 0.2% . The 0.2% increase is a net reflection of the 0.6% increase in the Consumer Pricing Index for Urban Areas (CPI-U) from June 2019 through June 2020, combined with the annual Multi-Factor Productivity Adjustment (MFP) of -0.4% . Click here to view and download the complete 2021 Medicare DMEPOS fee schedule

CMS Announces the Resumption of Medicare Audits

The Centers for Medicare and Medicaid Services (CMS) has authorized its Medicare contractors (e.g. DME MACs, RACS, SMRCs, etc.) to once again perform pre-payment and post-payment audits as part of their medical review responsibilities, starting on August 3, 2020.  CMS had suspended most audits as of March 30, 2020 due to the COVID-19 Public Health Emergency (PHE).  CMS indicates that if individual providers are selected for medical review believe that responding to a request for documentation will create a hardship situation, they should discuss response options with the contractor performing the review. Click here for more information.

CGS and/or Noridian are currently conducting post payment reviews for claims with the following codes:A5500, A5512, A5513, A5514, L0457, L0631, L0648, L0650, L1833, L1851, L1902, L1906, L1940, L1970, L1971, L4360, L4361, L4396, L4397, L5700, and L5701

Medicare Medical Policies

Lower Limb Prostheses: LCD & Policy Article

Ankle-Foot/Knee-Ankle-Foot-Orthosis: LCD & Policy Article

Spinal Orthoses(TLSO and LSO): LCD & Policy Article

Knee Orthoses: LCD & Policy Article

External Breast Prostheses: LCD & Policy Article

Diabetic Shoes/Inserts: LCD & Policy Article

Orthopedic Shoes/Inserts: LCD & Policy Article

Standard Documentation Requirements: Local Coverage Article