Remark code M112 is an indication that the reimbursement for the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item being billed is subject to the single payment amount established under the DMEPOS Competitive Bidding Program for the geographic area in which the patient lives. This means that the payment for the item is not based on the usual fee schedule but on the competitively bid rate determined for that specific region. Providers should ensure that their billing reflects these competitive bidding rates to avoid discrepancies in reimbursement.
Common causes of code M112 are:
1. The item being billed is included in the DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) Competitive Bidding Program, and the claim has been submitted with a payment amount that differs from the established Single Payment Amount (SPA) for the patient's geographic area.
2. The healthcare provider may not be contracted with Medicare as a Competitive Bidding Program supplier for the specific item or service, yet they have provided and billed for the DMEPOS item.
3. The claim was submitted without proper indication that the item is subject to competitive bidding, leading to a discrepancy in the expected reimbursement amount.
4. There may be an error in the claim submission where the geographic area was incorrectly coded or the SPA was not accurately applied according to the patient's residence.
5. The claim could have been submitted for a patient who has recently moved, and the address on file does not match the current Competitive Bidding Area (CBA) where the patient now resides, causing a mismatch in the payment amount.
6. The healthcare provider may have failed to update their billing system with the latest SPAs, resulting in claims being submitted with outdated payment amounts.
7. The item or service might have been miscoded, and the code used does not match the item or service that is included in the competitive bidding program for the patient's area.
8. There could be a lack of necessary documentation to support the claim, such as a Certificate of Medical Necessity (CMN) or a physician's prescription, which is required for certain DMEPOS items under the Competitive Bidding Program.
Ways to mitigate code M112 include ensuring that the billing team is aware of the current Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program payment amounts for the patient's geographic area. It is important to regularly update the fee schedules in your billing system to reflect these amounts. Additionally, verify the patient's residence and ensure that the correct pricing is applied based on their location before submitting claims. Training staff to recognize items subject to competitive bidding and implementing a system to flag these items can also help prevent this code from arising. Regular audits of billing practices for DMEPOS items can further reduce the likelihood of encountering code M112.
The steps to address code M112 involve verifying the patient's residence and ensuring that the claim reflects the appropriate competitive bidding area (CBA) pricing. Review the item in question to confirm it falls under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. If the item is correctly classified, adjust the claim to match the single payment amount specified for the CBA. If the item or the patient's residence has been misidentified, correct the information and resubmit the claim. Additionally, check for any recent changes in competitive bidding areas or payment amounts, as these can affect reimbursement rates. If necessary, contact the DME Medicare Administrative Contractor (MAC) for guidance on pricing and resubmission procedures.