Author: DME INFO

Current Orthopedic and DME news and resources.

Widespread Prepayment Probe for HCPCS Code L4360 (Pneumatic Walking Boot)

Posted on by DME INFO

DME MAC A will be initiating a widespread prepayment probe of claims for the following HCPCS code:

L4360 (WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE)

This review is being initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.  Please click here to see entire article: L4360 Probe

Split Coding…..have you adjusted?

Posted on by DME INFO

We recently passed the one year mark of the roll-out of CMS’s changes to HCPCS coding for orthotics.  If you have been tracking this issue, you know that CMS made significant changes to the coding structure by establishing two separate categories of HCPCS orthotic codes:  Off-the-Shelf (OTS) and Custom Fitted (CST).  We thought this would be a good time to review these changes and their implications.

As a reminder, the CMS definitions for OTS and CST orthotics are included below:

OTS Orthotics:  Require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. Minimal self-adjustment is an adjustment that the beneficiary, caretaker for the beneficiary, or a supplier of the device can perform and that does not require the services of a certified orthotist or an individual who has specialized training.

Custom Fitted Orthotics:  Require fitting by someone with specialized education, training, and experience in fitting and certification and/or licensing.

You can read more about the changes and what it means to you by clicking here, here and here.

If you are a DJO customer you have probably noticed that DJO now lists two recommended HCPCS codes on applicable product labels:  one code for OTS and another for CST.  Each customer should carefully review the CMS requirements to determine which is the most appropriate code to bill.  Although, for now, the Medicare reimbursement for an OTS code is the same as a CST code, you must still meet the Medicare CST requirements when you bill a CST code. Failure to do so could subject you to Medicare repayments and even fines in the face of a Medicare audit.

For commercial payors, this change has created quite a bit of confusion.  While most commercial payors are recognizing the new codes, there are still some that do not.  We recommend that you check with your commercial payors to see how they are addressing the new coding structure.  Depending on what you find out, you may want to check your payor contracts to determine if updates are indicated. For example, are the OTS codes listed and, if so, is there an associated fee schedule?  And don’t forget to audit your payments to ensure you are getting paid appropriately by both Medicare and private payors.

If you would like more information or have questions about these changes please feel free to reach out to your local DJO representative.

2015 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

Posted on by DME INFO

For CY 2015, the update factor of 1.5 percent is applied to the applicable CY 2014 DMEPOS fee schedule
amounts.  For more information and to download the 2015 DMEPOS Fee Schedule please click these links:

CMS Transmittal 3129         2015 Fee Schedule Downloads

Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.

Posted on by DME INFO

On October 31, 2014, CMS released the final rule:  Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.

The provision that the bracing industry has been following pertains to the definition of minimal self-adjustment of orthotics.  In the fact sheet accompanying the ESRD/DMEPOS provisions (http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-31-3.html), CMS notes that it is not changing regulatory requirements for specialized training, but program guidance remains in effect:

This rule will not finalize an update to the regulation reflecting program guidance on what specialized training is needed to provide custom fitting services if providers are not certified orthotists.  Although the regulation is not being updated at this time, the program guidance still stands.

The program guidance that remains in effect may be referenced here:  http://cgsmedicare.com/jc/pubs/news/2014/0314/cope25125.html.  There is no prohibition on manufacturer reps (or orthotic fitters, athletic trainers, etc.) providing the fitting if the standards below are met.

Custom fitted orthotics are:

  • Devices that are prefabricated
  • They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted
  • Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment
  • This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary

Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements.

As a result of this rule and the lack of CMS clarification around an individual with specialized training, manufacturer’s sales reps may continue to fit custom fitted orthotics as long as the above listed requirements are met.

 

Two new off-the-shelf (OTS) knee orthosis codes are effective today October 1, 2014:

Posted on by DME INFO

The following two new off-the-shelf (OTS) knee orthosis codes are effective today October 1, 2014:

K0901    KO Single Upright Pre OTS             Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

K0902    KO Double Upright Pre OTS           Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

These new codes are the OTS versions of L1843 and L1845 respectively, and join the 23 other OTS codes that CMS established as part of the 2014 HCPCS update.  This means that if a product currently coded L843 or L1845 requires only minimal self-adjustment for fitting at the time of the delivery, these new OTS “K” codes are the ones that should be billed to the DME MACs.

The updated fee schedule can be accessed here:  http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS_Quarterly_Update.html