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

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


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?

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.

Provider Services Portal Invitation

The Centers for Medicare & Medicaid Services (CMS) authorized NHIC, Corp. to design and operate the Provider Services Portal (PSP) to offer DME MAC Jurisdiction A suppliers a means to access beneficiary eligibility and claims information over the Internet. PSP offers an electronic, web-based alternative to the processes of calling or writing the Customer Service Center, or calling the IVR for information.

PSP offers the following information through lookup transactions:

  • Beneficiary Eligibility
  • Claim Status
  • Standard Paper Remittance (SPR)
  • Same/Similar

PSP is available 24 hours a day, 7 days a week, except during scheduled maintenance windows.

At this time, NHIC is offering PSP Open Enrollment to all DME MAC Jurisdiction A suppliers.  Please click here for more information

Medicare Provider-Supplier Enrollment

CMS has established Internet-based Provider Enrollment, Chain and Ownership System (PECOS) as an alternative to the paper (CMS-855) enrollment process. Internet-based PECOS will allow physicians, non-physician practitioners and provider and supplier organizations to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, or check on status of a Medicare enrollment application via the Internet. For more information about the Internet-based PECOS, please CLICK HERE

HCPCS Code L0430 – Invalid

Effective for dates of service on or after November 17, 2012, Healthcare Common Procedure Coding System (HCPCS) code L0430 (SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL, CUSTOM FITTED (DEWALL POSTURE PROTECTOR ONLY)) will be invalid for claim submission to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs).  Products previously coded L0430 by the Pricing, Data Analysis and Coding (PDAC) contractor and posted to the Durable Medical Equipment Coding System (DMECS) will be end dated on November 17, 2012.  Please click here for more information.