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:
Category: Medicare
Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.
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:
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
CMS Implements Fingerprint – based Background Checks
Fingerprint-based background checks will be required for all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls into the high risk category and is currently enrolled in Medicare or has submitted an initial enrollment application. The fingerprint-based background requirement was implemented on August 6, 2014, and will be conducted in phases. Providers or suppliers will receive notification of the fingerprint requirements from their MAC. Initially, not all providers and suppliers in the “high” screening category will be a part of the first phase of the fingerprint-based background check requirement. If you receive notification of the fingerprint requirements, you will have 30 days from the date of the letter to be fingerprinted. Make sure that your staffs are aware of these requirements. For more information please click here FINGERPRINTS
CMS Restarts Parts of the RAC Program
The Centers for Medicare and Medicaid Services is restarting the controversial Recovery Audit Contractor Program—in a limited fashion—in August.
CMS sent a communication on August 4 to congressional health staff members from Lauren Aronson, Director of the Office of Legislation at CMS, informing them of the decision.
“Today, the Centers for Medicare and Medicaid Services announced plans to modify contracts with current Recovery Auditors to allow for a limited number of Medicare fee-for-service claim reviews beginning in August 2014,” states the communication. “Current Recovery Auditors will conduct a limited number of automated reviews and a small number of complex reviews on certain claims including, but not limited to: spinal fusions, outpatient therapy services, durable medical equipment, prosthetics, orthotics and supplies; and cosmetic procedures. The Recovery Auditors will not conduct any inpatient hospital patient status reviews during this limited restart period.” To read entire announcement, please click here RAC PROGRAM
DME INFO 