Revised Local Coverage Determination (LCD) for Knee Orthoses (L27263)

A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) and has one of the diagnoses listed in the ICD-9 Diagnosis Codes That Support Medical Necessity Group 2 Codes section.   To read the entire revision please click  REVISED LCD KNEE

Implementation of Fingerprint-Based Background Checks

As part of the enhanced enrollment screening provisions contained in the Affordable Care Act the Centers for Medicare & Medicaid Services (CMS) is implementing fingerprint-based background checks. The fingerprint-based background checks will be used to detect bad actors who are attempting to enroll in the Medicare program and to remove those currently enrolled. Once fully implemented, the fingerprint-based background check will be completed on all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls under the high risk category. For more information please click here MLN Matters

Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid

Today, as part of the Obama administration’s work to make our health care system more transparent, affordable, and accountable, Health and Human Services (HHS) Secretary Kathleen Sebelius announced the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.  Please click here for more information.

President Obama Signs Medicare Physician Fee Schedule/SGR Patch with Numerous Health Policy Provisions

ReedSmith reported today that on April 1, 2014, President Obama signed into law H.R. 4302, the “Protecting Access to Medicare Act of 2014” (“the Act”). The Act includes a one-year Medicare physician fee schedule fix that averts a nearly 24 percent payment cut set for April 1, 2014, but which falls far short of earlier hopes for full repeal of the current sustainable growth rate (SGR) formula. The Act also includes numerous other Medicare payment and policy changes, including skilled nursing facility value-based purchasing provisions, reforms to the physician fee schedule relative valuation process, a new framework for clinical laboratory payments, a variety of changes impacting imaging services, changes in the exceptions for long term care hospitals, and extension of certain expiring provisions. In other areas, the bill includes a one-year delay in the transition to ICD-10, changes to the timetable for Medicaid disproportionate share hospital cuts, and “front-loading” of the 2024 Medicare sequestration reduction.


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PDAC Process to re-classify orthotic products as Off-The-Shelf

Noridian Healthcare Services reports that effective January 1, 2014, the Centers for Medicare & Medicaid Services (CMS) established 23 new HCPCS codes to describe Pre-Fabricated Off-The-Shelf (OTS) orthoses and revised the HCPCS code description for 29 existing codes describing Pre-Fabricated Custom-Fitted orthoses. These changes were outlined in the Advisory Article titled HCPCS Code Update (2014) which was posted to the PDAC website on January 3, 2014. The link is provided here for your convenience:

Products that are currently listed on the Durable Medical Equipment Coding System (DMECS) with any of the 29 HCPCS codes that were revised, can no longer be considered fully “code verified” by the PDAC under the new definitions. While the product(s) fits the general category of its currently designated HCPCS code, the PDAC needs to further differentiate if products are only OTS, only custom-fitted, or possibly both.

PDAC is undertaking the task of reviewing all products currently on DMECS affected by these coding changes to ensure DMECS is updated with the correct coding assignments. We are currently in the process of contacting the manufacturers of products listed on DMECS and asking them to identify which product(s) they consider as being only OTS. As we receive these responses, we will update DMECS. A coding verification application will not be required to re-classify an existing product listed on DMECS to the appropriate OTS HCPCS code.

Off-the-Shelf orthotics under Medicare are statutorily defined by law in Title 18 of the Social Security Act [section 1847(a)(2)(C)], and also in Federal Regulations at 42 CFR §414.402 asorthotics described in section 1861(s)(9) of the Act that require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling or customizing to fit a beneficiary.

Minimal Self-Adjustment is defined at 42 CFR §414.402 Subpart F: Minimal self-adjustment means an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and does not require the services of a certified orthotist (that is, an individual certified by either the American Board for Certification in Orthotics and Prosthetics, Inc., or the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.

Due to the high volume of products currently listed on DMECS with these revised codes, we are contacting manufacturers in segments. If you haven’t received a notice from the PDAC yet, it will be forthcoming over the next several months. If you have products currently listed on DMECS that you consider only OTS under the new codes, PDAC is requesting that you please wait to be contacted by us before taking any action or submitting a coding verification application. As noted above, submission of a coding verification application to the PDAC is not necessary for products currently listed on DMECS to be classified as OTS.

For further questions about this process, please contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website: