Additional States Requiring Payment Edits for DMEPOS Suppliers of Prosthetics and Certain Custom-Fabricated Orthotics - Update to CR3959 and CR8390

MLN Matters® Number: MM8730
Related Change Request (CR) #: CR 8730
Related CR Release Date: May 16, 2014
Related CR Transmittal #: R1385OTN
Effective Date: March 3, 2014
Implementation: June 17, 2014

Provider Types Affected
This MLN Matters® Article is intended for DMEPOS suppliers in Alabama, Arkansas, Florida, Georgia, Illinois, Kentucky, Mississippi, New Jersey, Ohio, Oklahoma, Rhode Island, Tennessee, Texas, Washington, North Dakota, Iowa, and Pennsylvania who bill Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Prosthetics and Orthotics (P&O) provided to Medicare beneficiaries.

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8730 announce the three additional states that require the use of a licensed/certified orthotist or prosthetist for furnishing of P&O. The states are North Dakota, Iowa, and Pennsylvania.

Background
CMS issued Transmittal 656, CR3959 on August 19, 2005. This CR instructed Durable Medical Equipment Regional Contractors (DMERCs, since changed to DME MACs) to implement claims processing edits to ensure compliance with CMS regulations found at 42 CFR Section 424.57(c)(1). Such regulations require DMEPOS suppliers wishing to bill Medicare to operate their business and furnish Medicare-covered items in compliance with all applicable Federal and State licensure and regulatory requirements.

As a result of CR3959, the DME MACs implemented an edit which was programmed to deny claims for prosthetics and certain custom-fabricated orthotics when those items were furnished by personnel who were not licensed/certified as a orthotist or prosthetist by the State in which they practice. At the time CR3959 was issued and the DME MACs implemented the edit, there were nine states requiring the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics. Since that time, five additional states have instituted requirements for the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics. These five states are Arkansas, Georgia, Kentucky, Mississippi, and Tennessee. CR8390 instructed the DME MACs to revise the programming edits so that Arkansas, Georgia, Kentucky, Mississippi, and Tennessee are added to the logic, in accordance with CR3959.

CR8730 requires DME MACs to revise the programming edits so that North Dakota, Iowa, and Pennsylvania are added to the logic, in accordance with CRs 3959 and 8390.

In the 17 states that have indicated that provision of prosthetics and orthotics must be made by licensed/certified orthotist or prosthetist, Medicare payment may only be made for prosthetics and certain custom-fabricated orthotics when furnished by physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel, and prosthetics personnel. These specialties will bill for Medicare services when State law permits such entity to furnish an item of prosthetic or orthotic using the following codes:

  • Medical Supply Company with Orthotics Personnel – Specialty Code 51;
  • Medical Supply Company with Prosthetics Personnel – Specialty Code 52;
  • Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53;
  • Orthotics Personnel – Specialty Code 55;
  • Prosthetics Personnel – Specialty Code 56;
  • Orthotics Personnel, Prosthetics Personnel, and Pedorthists – Specialty Code 57;
  • Physical Therapist – Specialty Code 65;
  • Occupational Therapist – Specialty Code 67;
  • Pedorthic Personnel - Specialty Code B2;
  • Medical Supply Company with Pedorthic Personnel - Specialty Code B3;
  • Ocularist – Specialty Code B5; and
  • All Physician Specialty Code listed in the "Medicare Claims Processing Manual," Chapter 26, Section10.8.2, which is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf on the CMS website.

If a supplier is located in one of the applicable states, that supplier must be properly enrolled with the National Supplier Clearinghouse (NSC) to ensure the correct specialty code(s) is on file in order to submit a claim to Medicare for the prosthetics and custom-fabricated orthotics. Failure to be properly enrolled will result in the claim being denied. A copy of the State license should be sent to the NSC if the supplier is in one of the seventeen states requiring a license.

If a supplier should need to update its' file with the correct specialty, the supplier must submit a "Change of Information" on Form CMS-855S to the NSC along with all applicable licenses or certifications. That form is available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855s.pdf on the CMS website. The NSC is responsible for maintaining a central data repository for information regarding suppliers. The NSC transmits this repository to the four DME MACs. The effective date for the new or revised specialty code for P&O claims will be the date the NSC issues the specialty code. The new or revised specialty code will not be applied retroactively.

Additional Information
The official instruction, CR8730 issued to your DME MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1385OTN.pdf on the CMS website.

To review the article related to CR8390, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8390.pdf on the CMS website.

To review the CR3959, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM3959.pdf on the CMS website.

 

            Last Updated Tue, 04 Feb 2020 15:59:58 +0000