Custom Cushion and Backs REVERT BACK to Individual Pricing!

Posted on in Billing/Reimbursement, HME Government Issues

By Dan Fedor, VGM Reimbursement Specialist

About a month ago, DME MACs B and C (GCS) decided to establish a fee for the custom cushion and back codes (E2609 and E2617, respectively) without notifying the provider community. Because these items are custom (misc.), they were manually priced under individual consideration prior to this change. The fees they established were a significant reduction (60 percent lower) than previously priced claims. 

The CRT industry strongly voiced concern with this change, and as a result, CGS has decided to revert back to individual consideration pricing for these codes! Also because these codes are custom (misc.), the information on the attachment must be provided in the extra narrative field in order for them to process and establish pricing. You must provide the Supplier Price List (supplier charge, MSRP, etc.).

Current Pending Claims

On April 26, DME MACs B and C will begin processing all pending claims. For claims that have all necessary pricing documentation, they will process under individual consideration. For claims that don’t have sufficient pricing documentation, they will reach out to the supplier and request the necessary documentation to appropriately price under individual consideration.

Previously Paid Claims at the Lower Set Fee

Claims that paid at the lower fees will be reopened. DME MACs B and C plan to reach out to the supplier to request pricing documentation, reopen the claims, and pay under individual consideration as they were priced in the past.

While CGS initially indicated that it does not intend to go back to individual claim consideration, it has subsequently decided that this is still a viable option and may very well be its final resolution. CGS plans to publish detailed guidelines to the provider community with the proper claims submission for these HCPCS codes.

CGS is still evaluating the establishment of local fees for these two codes. If local fees are established at a later date, CGS will notify providers through normal communication channels (ListServ, bulletin articles, POE).

We will keep a close watch on this and provide input as to why CGS should abandon the thought of establishing a set fee for a custom item such as these. While we are pleased CGS has reverted back to individually pricing these codes for now, we are still concerned with how this came about without any notice and plan to address that with the DME MAC, CMS, and Congress.

If you have any questions, please contact me at 570-499-8459 or [email protected].