CMS Delays 2005 Oxygen Fee Schedule
The Centers for Medicare and Medicaid Services (CMS) announced that it will continue to pay the 2004 Medicare fee schedule amounts for home oxygen and equipment until the new 2005 fee schedule amounts are computed. CMS indicated that it will not be able to compute the amounts because it did not receive necessary information from the Office of Inspector General (OIG) by January 15, 2005, as expected.

Due to the delay, CMS has decided to stop holding oxygen claims and will begin paying claims with 2005 dates of service based on the 2004 Medicare fee schedule amounts. These are the rates that would have otherwise been in effect. Once the OIG information is received and the 2005 fee schedule amounts are calculated, all claims received with dates of service on or after January 1, 2005, will be paid using the 2005 fee schedule amounts. Claims with dates of service on or after January 1, 2005, that were paid using the 2004 fee schedule amounts will not be retroactively adjusted after the 2005 fee schedule amounts are implemented. “Our hope is that the final OIG numbers reflect our concerns. We are very pleased that CMS and OIG are taking the time to give this matter the attention it deserves,” says Kay Cox, president and CEO of the American Association for Homecare. “Since CMS will continue to pay using the 2004 fee schedule, and will not hold up any claims, and will not retroactively adjust claims once the 2005 fees are implemented, this is great news for providers and patients.”

Medicare Releases 2005 Drug Therapy Codes
Medicare recently announced respiratory reimbursement and drug therapy codes in its first quarter drug price schedule for 2005. For inhalation drug therapies in 2005, Medicare indicated that code G0371 applies to the pharmacy dispensing fee of $57 for inhalation drugs, per 30 days. Code G0374 applies to the pharmacy dispensing fee for inhalation drugs, per 90 days. Effective January 1, Medicare will pay one dispensing fee for inhalation drugs furnished through DME for each 30- or 90-day period, regardless of the number of shipments or drugs dispensed during the supply period. The schedule also states that Medicare includes the cost of compounding drugs in the dispensing fees, and that both the drug and the dispensing fee must be billed on the same claim. New codes are also in effect for albuterol unit dose, J7613; ipratropium bromide, J7644; and albuterol compound solution, J7616. The schedule states that a unit dose of albuterol has a 7-cent payment limit, while the payment limit for ipratropium is at 29 cents per milligram.

Medicare Expands Coverage for Diabetes Insulin Pumps
CMS recently announced it will expand coverage of insulin infusion pumps for diabetes, a final coverage decision effective immediately. The organization also indicated that insulin pumps have been covered since 1999 for diabetic patients who had specific levels of C-peptide in the blood. The final National Coverage Determination (NCD) will allow coverage of an alternative test, called beta cell autoantibody, to identify beneficiaries with type 1 diabetes who would benefit from the pump. The decision will also expand the coverage of insulin pumps for patients with type 2 diabetes by standardizing the C-peptide testing and relaxing the criteria for those with kidney disease.

Clinicians Support Changing Medicare Wheelchair Coverage Criteria
A clinician task force recently announced support for an Interagency Wheelchair Work Group (IWWG) recommendation that “bed or chair confined” no longer be used as a criterion for qualifying Medicare beneficiaries for powered mobility equipment, and it can be replaced by a more functional standard. The recommendations were released when CMS disclosed they were launching a National Coverage Determination (NCD), a process that would create a new national coverage policy for mobility equipment. “This is a step in the right direction for clinicians, their patients, and advocates for people with disabilities,” says Laura Cohen, PhD, PT, ATP, co-coordinator of the Clinician Task Force of the Coalition to Modernize Medical Coverage of Mobility. Cohen says the criteria for Medicare coverage should be based on permitting a level of safe and efficient mobility that allows a patient to remain integrated into society and the work force; allows a patient to continue living with family (therefore avoiding premature institutionalization); or allows a patient to minimize the need for caregiver assistance for mobility-related tasks that can still be accomplished independently. Cohen also said clinicians were alarmed that CMS restricted the IWWG’s work to within the agency’s coverage interpretation of “used in the patient’s home.”

Clinicians claim the “in the home” requirement fails to recognize the benefits that come from allowing a person with limited mobility to perform activities outside the house. “We are hoping that over the course of establishing the NCD, contributions from clinicians will continue to be heard, and CMS will incorporate more of the provisions that will create clear consistent guidance, allowing individuals with mobility needs access to appropriate and necessary devices,” says Barbara Crane, PhD, PT, ATP, and also a co-coordinator of the Clinician Task Force.

Rural Add-On Reintroduced
Rep Greg Walden (R-Ore) reintroduced his bill to extend for 2 years the rural add-on payment for home health care. Due to distance traveled, rural home care delivery costs can sometimes be 12% to 15% higher than home care in more urban areas. The current add-on is set to expire in April 2005.

Crapo Moves to Senate Finance; Ross Appointed to House Energy and Commerce
Sen Mike Crapo (R-Idaho), chair of the Congressional COPD Caucus, will join the Senate Finance Committee. The Committee oversees Medicare, tax policy, Social Security, and other issues.

Rep Mike Ross (D-Ark) was recently appointed to serve on the powerful House Committee on Energy and Commerce, which influences law in many vital areas, including health care. The Committee has jurisdiction over the Department of Health and Human Services and the Food and Drug Administration, among other agencies.

“As an owner of a family-run home care business, Congressman Ross understands the importance of home care to millions of patients as well as the key role that home care plays in controlling health care costs,” says Kay Cox, president and CEO of the American Association for Homecare.

Get the Story Behind the Story In the fast-paced world of HME legislative and industry news, you need more than just headlines. Dealer/Provider magazine’s “Midweek Analysis” email service features the thoughts and opinions of the people making the news. Signing up is easy and completely free, and your email address remains strictly confidential. Simply go to www.hhcdealer.com and click on the “Midweek Analysis” logo.