2026-08-20 - DMEPOS Competitive Bidding Program: Get Ready for Round 2028

REQUIREMENTS: 1. IMMEDIATE (Before processing Encelto claims): - Billing team: Update billing software to recognize HCPCS code J3403 (revakinagene taroretcel-lwey, per implant) for ASC and hospital outpatient claims. - Billing team: Implement fractionated unit billing logic in claims system for J3403. When splitting payment amounts, ensure claims are submitted with LU modifier (fractionated billing) and 76 modifier (repeat service) appended. - Billing team: Configure system to enforce the following rules for J3403: * Maximum 1 total unit per date of service per eye treatment * Support decimal unit increments (0.1 or 0.2 preferred) * Calculate fractionated charges correctly (e.g., for $261,579.65 payment: 9 claims at 0.1 unit/$26,157.96 + 1 claim at 0.1 unit/$26,158.01 if using 0.1 increments) - Providers: Review Medicare Claims Processing Manual Chapter 32, section 400.2.5 for CAR-T therapy billing parallels. - Consequence: Claims for Encelto submitted without proper fractionated billing and modifiers will be denied or processed incorrectly. 2. By January 1, 2027: - Billing/Coding team: Review and implement ICD-10 and other coding revisions to National Coverage Determinations (January 2027 Update) in billing system and encoder software. - Update encounter forms and templates to reflect new coding requirements. - Consequence: Claims submitted with outdated codes may be denied or incorrectly processed. 3. Before Bidding Period Opens (DMEPOS Round 2028): - DMEPOS bidders: Review all four new fact sheets on the CBIC website (Antitrust Guidance, Common Ownership & Common Control, Determining Number of Contract Awards & Single Payment Amount, Round 2028 Terms & Definitions). - Update bid preparation materials and bid surety bond amounts based on FY 2027 Inpatient Rehabilitation Facility Prospective Payment System final rule for remote item delivery competitive bidding areas. - Consequence: Non-competitive or non-compliant bids may be rejected.