What is Competitive Bidding and What Does it Mean for Me?
On October 27th of this year, the Centers for Medicare & Medicaid Services (CMS) announced the single payment amounts (SPAs) for the Off-The-Shelf (OTS) Back Braces and OTS Knee Braces product categories included in Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) and began awarding contracts in certain competitive bidding areas (CBAs).
When a new round of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program becomes effective, beneficiaries with Original Medicare who live in or travel to a competitive bidding area (CBA) and are prescribed off-the-shelf (OTS) back braces or OTS knee braces must use a competitive bidding contract supplier, unless an exception applies.
The following is an overview of two of these exceptions for:
- Physicians and other treating practitioners (physician assistants, nurse practitioners, and clinical nurse specialists); and
- Physical therapists and occupational therapists
From January 1, 2021, thru December 31, 2023, the CBP will be in effect for OTS back and knee braces. The guidance in this email only applies to these items during this time.
HOW DO YOU DETERMINE IF AN AREA IS IN A CBA?
CBAs are defined by ZIP Codes. To determine if a ZIP Code is in a CBA, enter it in the “FIND A CBA” tool on the tool bar at the top of the page at http://www.dmecompetitivebid.com. The “FIND A CBA” will also indicate the specific round that applies to a ZIP Code.
If you are not located within a CBA, it’s business as usual for at least the coming year.
Certain areas located within a CBA have faced more significant reductions in reimbursement than others. In many localities the reduction for OTS bracing is so small that you may not need to change anything at this time. You may find a complete listing of the allowable fee schedule in your area here.
WHAT REQUIREMENTS MUST BE MET TO QUALIFY FOR THESE EXCEPTIONS?
Medicare physicians, physician assistants, nurse practitioners, and clinical nurse specialists who are enrolled as Medicare DMEPOS suppliers via Form CMS-855S have the option to furnish OTS back braces and OTS knee braces to their own patients without being a contract supplier if both of the following requirements are met:
- The OTS back brace or OTS knee brace must be furnished by the physician or other treating practitioner to his or her own patient as part of his or her professional service.
- The OTS back brace or OTS knee brace must be billed to a Durable Medical Equipment Medicare Administrative Contractor (DME MAC) using the DMEPOS billing number that is assigned to the physician, the treating practitioner (if possible), or the group practice to which the physician or other treating practitioner has reassigned the right to receive Medicare payment.
*Note: This exception does not affect the applicability of the physician self-referral (Stark law) provisions in section 1877 of the Social Security Act. All provisions of the physician self-referral law remain fully in effect.
WHAT PAYMENT RULES APPLY UNDER THESE EXCEPTIONS?
Medicare pays competitive bidding single payment amounts (SPA) for OTS back braces and OTS knee braces furnished under these exceptions, and assignment of the claim must be accepted in all cases. SPAs can be found here, on the Competitive Bidding Implementation Contractor (CBIC) website.
WHAT ARE THE RULES TO BILL FOR OTS BACK BRACES AND OTS KNEE BRACES FURNISHED UNDER THESE EXCEPTIONS?
To be paid for OTS back braces as a non-contract supplier, physicians and other treating practitioners should use the modifier KV and physical therapists and occupational therapists should use the modifier J5 in combination with the following HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650 and L0651.
To be paid for OTS knee braces as a non-contract supplier, physicians and other treating practitioners should use the modifier KV and physical therapists and occupational therapists should use the modifier J5 in combination with the following HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852.
On the claim billed to the DME MAC, the OTS back brace or OTS knee brace line item must have the same date of service as the professional service office visit or physical or occupational therapy service billed to the Part A/Part B MAC.
Physicians and other treating practitioners and physical therapists and occupational therapists are advised to submit the office visit or therapy claim and the OTS back brace or OTS knee brace claim on the same day to ensure timely and accurate claims processing.
Adapting to Survive Competitive Bidding
In contrast with our previous article regarding competitive bidding, you DO NOT have to use the semi-custom code (L1843) and complete the fitting note to be exempt from the CBA requirement. There is an exception for physicians that are dispensing OTS back and knee braces in the office to their own patients. It is our understanding that in this scenario they will be paid the CBA rate for their geographic area when billing an OTS product such as L1851.
Check out the national fee schedule for reference here.
If you need a refresher course on how to apply the OAide-3000™ Single Hinge Unloading Knee Brace to your patients, you may find a helpful instructional video on how to fit the brace below.
Should you have any additional questions or concerns about how to adjust your standard operating procedures to comply with the upcoming competitive bidding system changes please feel free to contact us at:
Integrative Practice Solutions
Phone: (855) 854-6332
Fax: (727) 683-9536
- DMEPOS Competitive Bidding Program: MLN Fact Sheet Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists
- National Fee Schedule: https://d15k2d11r6t6rl.cloudfront.net/public/users/Integrators/BeeProAgency/379826_359226/DMEPOS_Jan.csv
About the Author: Lance Liberti is a nationally recognized healthcare consultant and new patient marketing professional with more than a decade of practical experience in the field. His experience spans multiple areas of practice including non-surgical spinal decompression, medically supervised weight loss, aesthetic medicine, and non-operative extremity pain management. The president and CEO of Integrative Practice Solutions, Inc. Mr. Liberti specializes in assisting health and wellness professionals integrate boutique medical services into their practices to offer non-surgical solutions to those suffering from various degenerative musculoskeletal conditions. To learn more about Mr. Liberti’s extensive experience and see examples of his work products view his LinkedIn profile here: https://www.linkedin.com/in/lanceliberti
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