Category: DME Information

Are you ready for ICD-10?

Posted on by DME INFO

Why Transition to ICD-10?

A directive from CMS requiring healthcare providers, payers, clearinghouses, and billing services to comply with the transition to ICD-10 by 1 Oct 2015, which means:

  • All electronic transactions must use Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes.
  • ICD-10 diagnosis codes must be used for all health care services provided in the U.S., and ICD-10 procedure codes must be used for all hospital inpatient procedures.

ICD-10 Facts

  • ICD-10 has 69,000 codes—more than 4 times the 17,000 codes in ICD-9. The additional codes will enable practices to be more specific on claims forms in reporting the care provided to patients.
  • ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims.
  • The medical terminology has been modernized and is consistent throughout the code set.
  • There are codes that have a combination of diagnoses and symptoms, which improves the specificity of the reporting allowing for more information to be reported to completely describe a condition.

For additional information please click here ICD-10

CORRECT CODING – DEFINITIONS USED FOR OFF-THE-SHELF VERSUS CUSTOM-FITTED PREFABRICATED ORTHOTICS (BRACES) – REVISED

Posted on by DME INFO

Joint DME MAC Publication

This is a revision to a previously published article 3/28/2014.

As part of the 2014 and 2015 HCPCS update, codes were created describing certain OTS orthotics. Some of these codes parallel codes for custom fitted versions of the same items. Refer to the table at the end of this article for a listing of codes.

When providing these items suppliers must:

  • Provide the product that is specified by the ordering physician
  • Be sure that the ordering physician’s medical record justifies the need for the type of product (i.e., prefabricated versus custom fabricated)
  • Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
  • Have detailed documentation in the supplier’s record that justifies the code selected

Please click here to read the entire article

 

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