DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. <strong>The</strong> information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Reasonable Charge Update for <strong>2<strong>01</strong>1</strong> for Splints, Casts, and CertainIntraocular LensesMLN Matters® Number: MM7225Related Change Request (CR) #: 7225Related CR Release Date: November 19, 2<strong>01</strong>0Effective Date: <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>Related CR Transmittal #: R2100CPImplementation Date: <strong>January</strong> 3, <strong>2<strong>01</strong>1</strong>Provider Types AffectedThis article is for physicians, providers, and suppliers billing <strong>Medicare</strong> contractors (carriers, fiscalintermediaries [FIs], <strong>Medicare</strong> administrative contractors [MACs], and durable medical equipment<strong>Medicare</strong> administrative contractors [DME MACs]) for splints, casts, dialysis supplies, dialysisequipment, and certain intraocular lenses.Provider Action NeededChange Request (CR) 7225, from which this article is taken, instructs your carriers, FIs, and MACs how tocalculate reasonable charges for the payment of claims for splints, casts, and intraocular lenses furnishedin calendar year <strong>2<strong>01</strong>1</strong>. Make sure your billing staff is aware of these changes.BackgroundPayment continues to be made on a reasonable charge basis for splints, casts, and for intraocular lensesimplanted (codes V2630, V2631, and V2632) in a physician’s office. For splints and casts, the Q-codes areto be used when supplies are indicated for cast and splint purposes. This payment is in addition to thepayment made under the <strong>Medicare</strong> physician fee schedule for the procedure for applying the splint orcast.Beginning <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>, reasonable charges will no longer be calculated for payment of home dialysissupplies and equipment for Method II End-Stage Renal Disease (ESRD) patients. Section 153 of <strong>Medicare</strong>Improvements for Patients and Providers Act (MIPPA) amended section 1881(b) of the Act to require theimplementation of an ESRD bundled payment system effective <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>. <strong>The</strong> ESRD prospectivepayment will provide an all-inclusive single payment to ESRD facilities (i.e. hospital-based providers ofservices and renal dialysis facilities) that will cover all the resources used in providing outpatient dialysistreatment, including dialysis supplies and equipment that are currently separately payable to Method IIDME suppliers.CR 7225 provides instructions regarding the calculation of reasonable charges for payment of claims forsplints, casts, and intraocular lenses furnished in calendar year <strong>2<strong>01</strong>1</strong>. Payment on a reasonable chargebasis is required for these items by regulations contained in 42 CFR 405.5<strong>01</strong>. <strong>The</strong> Inflation Indexed Charge(IIC) is calculated using the lowest of the reasonable charge screens from the previous year updated by aninflation adjustment factor or the percentage change in the Consumer Price Index (CPI) for all urbanconsumers (United States city average) or CPI-U for the 12-month period ending with June of 2<strong>01</strong>0. <strong>The</strong><strong>2<strong>01</strong>1</strong> payment limits for splints and casts will be based on the 2<strong>01</strong>0 limits that were announced in CR 6691CPT codes and descriptors are only copyright 2<strong>01</strong>0 American Medical Association (or such other date publication of CPT)<strong>The</strong> <strong>Medicare</strong> <strong>Monthly</strong> <strong>Review</strong> 58 <strong>MMR</strong> <strong>2<strong>01</strong>1</strong>-<strong>01</strong>, <strong>January</strong> <strong>2<strong>01</strong>1</strong>
last year, increased by 1.1 percent, the percentage change in the CPI-U for the 12-month period endingJune 30, 2<strong>01</strong>0. <strong>The</strong> IIC update factor for <strong>2<strong>01</strong>1</strong> is 1.1 percent.A list of the <strong>2<strong>01</strong>1</strong> payment limits for splints and casts are as follows:Code Payment LimitA4565 $7.84Q40<strong>01</strong> $44.60Q4002 $168.58Q4003 $32.04Q4004 $110.92Q4005 $11.81Q4006 $26.62Q4007 $5.92Q4008 $13.31Q4009 $7.89Q4<strong>01</strong>0 $17.75Q4<strong>01</strong>1 $3.94Q4<strong>01</strong>2 $8.88Q4<strong>01</strong>3 $14.36Q4<strong>01</strong>4 $24.21Q4<strong>01</strong>5 $7.18Q4<strong>01</strong>6 $12.10Q4<strong>01</strong>7 $8.30Q4<strong>01</strong>8 $13.23Q4<strong>01</strong>9 $4.16Q4020 $6.62Q4021 $6.14Q4022 $11.08Q4023 $3.09Q4024 $5.54Q4025 $34.44Q4026 $107.54Q4027 $17.23Q4028 $53.78Q4029 $26.34Q4030 $69.33Q4031 $13.17Q4032 $34.66Q4004 $110.92Q4005 $11.81Q4006 $26.62Q4007 $5.92Q4008 $13.31Q4009 $7.89Q4<strong>01</strong>0 $17.75CPT codes and descriptors are only copyright 2<strong>01</strong>0 American Medical Association (or such other date publication of CPT)<strong>The</strong> <strong>Medicare</strong> <strong>Monthly</strong> <strong>Review</strong> 59 <strong>MMR</strong> <strong>2<strong>01</strong>1</strong>-<strong>01</strong>, <strong>January</strong> <strong>2<strong>01</strong>1</strong>
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