Administrative transmittals and program instructions that affect coverage, coding, and claims processing for the items and services described in this chapter. This group describes which transmittals are issued for the chapter and highlights administrative guidance that indicates no coverage or specific handling requirements.
Transmittals Issued for this Chapter: list of recent and historically relevant transmittals issued for topics covered in this chapter, including fee-schedule and file-layout updates, corrections, and implementation notices. Examples include transmittals for Supplies (DMEPOS) Fee Schedule (R2836CP), MPFSDB 2014 File Layout Manual (R2790CP), and corrections to the Claims Processing Manual (R2783CP).
Field-level and file-layout transmittals: CMS issues transmittals that modify file layouts and data field definitions used by MACs for fee schedules, MPFS supplemental files, institutional record layouts, and competitive bidding files. These transmittals must be applied according to their implementation dates and used to update local processing, mapping, and pricing files.
No-coverage / rejected-code transmittals and instructions: CMS transmittals and program instructions identify codes and modifiers that are not valid for Medicare (for example, HCPCS code A9270 is not accepted by A/B MACs for billed services except in specific DME supplier circumstances). MACs are instructed to reject or return claims containing deleted or discontinued HCPCS/ICD codes as unprocessable for dates of service after the effective discontinuation, and to follow HIPAA date-of-service requirements when applying code sets.
Modifier-based administrative denials: CMS instruction conveyed by transmittal and CRs requires that certain modifier usages be auto-denied or returned (for example, claims with a GZ modifier must be automatically denied for dates of service on or after July 1, 2011; submission of conflicting modifiers such as GZ together with GA/GY should be treated as invalid modifier combination and the claim may be unprocessable).
Fee-schedule and competitive bidding transmittals: CMS issues recurring update notifications and transmittals to publish single payment amounts, competitive bidding HCPCS categories, and quarterly updates. DME MACs must update competitive bidding files (HCPCS category file, bid pricing file, ZIP Code file, contract supplier file) as instructed and confirm receipt per the transmittal directions.
Laboratory and gap-fill transmittals: CMS transmittals instruct MACs on laboratory fee schedule access, annual updates, and the gap-filling process for new lab and DMEPOS codes. When gap-filling is required, MACs must follow the data submission formats and deadlines provided in transmittals and recurring update notifications.
Action required for MACs and providers: apply transmittal instructions by the specified implementation dates; update local fee and code files; reject/return claims containing discontinued codes or invalid modifier combinations per transmittal guidance; apply no-grace-period date-of-service rules when codes are discontinued; and follow transmittal directions for communicating receipt of CMS data files.
Operational note: Transmittals referenced in this chapter also include correction notices and implementation change logs (see transmittal identifiers and CR numbers listed in the Transmittals Issued for this Chapter). Providers should consult their MAC website and the CMS transmittal library for the full text and implementation specifics of each transmittal.