All Medicare Round 2021 Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program (CBP) Contracts for Off-the-Shelf (OTS) back braces and OTS knee braces expire on December 31, 2023. Starting January 1, 2024, there will be a temporary gap in the DMEPOS CBP.
The Centers for Medicare & Medicaid Services plans to conduct bidding for the next round of the DMEPOS CBP after going through notice and comment rulemaking to further strengthen the DMEPOS CBP.
For additional information on the gap period, please see the Temporary Gap Period (PDF) fact sheet and continue to monitor the CMS.gov and Competitive Bidding Implementation Contractor (CBIC) websites for updates.
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CMS Competitive Bidding
Healthcare leaders recognize patients as their most important area of focus. At the same time, however, overseeing business needs like inventory management, reimbursement, price transparency and staff shortages are top priorities. Significant opportunities exist for orthopedic clinics and ASCs to leverage automation to address these issues – but choosing the right solution can be daunting.
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CGS wants to remind suppliers and providers that orthotic devices are not covered if they do not meet the coverage criteria outlined in the Local Coverage Determinations (LCDs) for the HCPCS code prescribed at the time of service.
Devices provided prior to the start of medical necessity (for example, before the surgery), will not meet the coverage criteria. After surgery, if there is documentation of the medical necessity for the orthotic device(s), you can provide the item, keeping in mind there are many other payment rules related to the claim.
For orthotic devices that require Prior Authorization (PA) (L0648, L0450, L1832, L1833, and L1851), do not submit PA requests prior to the start of medical necessity (for example, before the surgery). After surgery, if the medical record documentation shows an emergent need for the device(s), you can submit an expedited request. If an expedited request is not feasible, append the ST modifier to the claim to bypass PA. Claims submitted with the ST modifier are subject to 100% prepayment review.
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The Centers for Medicare & Medicaid Services (CMS) released the 2023 durable medical equipment (DMEPOS) Medicare fee schedule with an increase of 8.7 percent.
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Pub 100-04 Medicare Claims Processing