Understanding Reimbursements for Fitting and Measuring for HME Providers

Published in Member Communities on January 08, 2025

Understanding Reimbursements for Fitting and Measuring for HME Providers By Craig Douglas, SVP of HME, Respiratory, and Wellness, VGM & Associates

It is well known that DME providers frequently encounter the challenge of not being reimbursed for the time spent with patients for fitting and measuring, particularly when time is spent taking measurements with a patient but ultimately no order is placed. Historically, CMS has consistently maintained that DME reimbursements are intended to not only cover the product itself, but also encompass the time spent on measuring, fitting, and educating the patient, as recently clarified in their explanation of compression garment coverage.

CMS's Decision on Compression Coverage

Following the passage of the Lymphedema Treatment Act and a subsequent comment period and deliberations, CMS clarified in their Final Rule CMS-1780-F that they would not establish a separate fee schedule for fitting and measuring patients for these products. Instead, a single billing code and associated reimbursement rate would cover both the product and the patient fitting process.

To review the comments submitted to CMS and their considerations, review pages 362-368 of this link. Here are some key points from CMS:

Inclusion of Fitting Services: CMS finalized the proposal to include payment for fitting services in the overall payment for lymphedema compression treatment garments provided by Medicare-enrolled DMEPOS suppliers.
Comments on Separate Payment: CMS acknowledged the concerns regarding separate payment for fitting services. They noted that therapists often take measurements and perform fitting services, which are integral to furnishing custom and standard garments. However, CMS decided against a separate payment policy due to its complexities.
Medicare Payments: Medicare payments include all services necessary for furnishing gradient compression garments, consistent with other DMEPOS items and services. CMS will monitor access to these items to ensure appropriate payments.

Implications for DME Providers

There is a precedent for DME fee schedules to include the product along with delivery, training, education, fitting, and measurements. CMS briefly considered separating the fitting/measurement process from the product but ultimately combined them. The rates were set to reflect this combination.

Without the background information outlined above, some may look at the current reimbursement rates and feel those rates only cover the product portion, and that there should be an opportunity for additional reimbursement to cover the measuring and fitting. However, after reading the comments submitted and the responses from CMS, it is clear they set the reimbursement rates at levels they believe account for the product as well as the time spent measuring, fitting, and educating the patient(s). Based on that information, it is our belief that had CMS taken a new stance of offering one reimbursement rate for the product itself, and then a separate and distinct code and rate for a fitting fee, the reimbursement rate for those two things together would likely not exceed the current combined reimbursement that they published. In other words, if the current allowable for an item is $100, splitting the product and fitting into separate billable items would still total $100. This could be divided in various ways, but the total reimbursement would remain the same. Billing as two separate line items could also allow another entity to receive the reimbursement for the fitting portion, which might not be ideal for DME providers.

With combined reimbursement, DME providers receive the fitting portion each time they provide a product, regardless of whether a full fitting is performed. This is beneficial in re-order scenarios where less time may be needed for fitting.

Future Considerations

CMS has stated that they will monitor patient access and consider adjustments if necessary. They also included language that allows the newly created benefit category to be included in future rounds of their competitive bidding program. Lastly, there remains a concerted effort by CMS to push more products and services into value-based care or alternative payment models. All of that points to future changes being possible at any point. Regardless of which type(s) of programs these products and services fall into in the future, when it comes to the financial viability of providing these products, the focus should remain whether the total reimbursement available to the supplier community is adequate, regardless of whether the reimbursement is split into two separately billable codes or combined into one. If you find yourself in a situation where current reimbursement does not cover the costs associated with providing certain products, you can’t be afraid to ask for improvements. To advocate for increased reimbursement, it is essential to show that patients cannot obtain necessary products due to current allowances.

TAGS