Competitive Bidding - JA DME
DMEPOS Competitive Bidding Program
Round 2021 is the current round of competitive bid and ONLY includes Off-The-Shelf (OTS) Knee Braces and OTS Back Braces.
The DMEPOS Competitive Bidding Program was mandated by Congress through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The statute requires that Medicare replace the current fee schedule payment methodology for selected Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items with a competitive bid process. The intent is to improve the effectiveness of the Medicare methodology for setting DMEPOS payment amounts, which will reduce beneficiary out-of-pocket expenses and save the Medicare program money while ensuring beneficiary access to quality items and services.
Under the program, a competition among suppliers who operate in a particular competitive bidding area is conducted. Suppliers are required to submit a bid for selected products. Not all products or items are subject to competitive bidding. Bids are submitted electronically through a web-based application process and required documents are mailed. Bids are evaluated based on the supplier's eligibility, its financial stability, and the bid price. Contracts are awarded to the Medicare suppliers who offer the best price and meet applicable quality and financial standards. Contract suppliers must agree to accept assignment on all claims for bid items and will be paid the bid price amount. The amount is derived from the median of all winning bids for an item.
Round 2021 Off the Shelf (OTS) Back and Knee Braces- The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) Round 2021 is divided into five phases. These phases have specific timeframes and goals. Four of the phases have been completed since August 16, 2019. The current phase is the active Round 2021 which ONLY includes Off-The-Shelf (OTS) Knee Braces and OTS Back Braces.
Competitive Bid 2021 Modifier Chart - OTS Knee and Back Braces
|Policy vs Competitive Bid Modifiers||Contract Supplier||Non-Contract Supplier||Physicians/Practitioners who are DME Suppliers||Physical and Occupational Therapists who are DME Suppliers|
|Modifiers per Policy||Knee - KX, RT, LT
Back - CG
|Knee - KX, RT, LT
Back - CG
|Knee - KX, RT, LT
Back - CG
|Knee - KX, RT, LT
Back - CG
|Modifiers for Competitive Bid||KT when applicable||KT when applicable||KV||J5|
|Modifier||Physician/Practitioner or Occupational Therapist (OT)/Physical Therapist (PT)|
|KV (physician/practitioner)/J5 (OT/PT)||A physician or OT/PT in a CBA is supplying an OTS brace to a beneficiary in a CBA as part of their professional service|
|KV/J5||Beneficiary travels from a CBA to a physician or OT/PT in a CBA and the OTS brace is supplied as part of their professional service|
|KV/J5||Beneficiary travels from a non-CBA to a physician or OT/PT in a CBA and the OTS brace is supplied as part of their professional service|
|KV/J5||Beneficiary travels from a CBA to a physician or OT/PT in a non-CBA and the OTS brace is supplied as part of their professional service|
|No modifier required||Beneficiary travels from a non-CBA to a physician or OT/PT in a non-CBA; competitive bid rules do not apply|
|Beneficiary in Competitive Bid Area||
|Billing for Orthotics Requiring Prior Authorization in Acute/Emergent Situations and Under Competitive Bidding Program||
CMS has given special consideration for acute situations for orthotics. Prior authorization requirements will be suspended for HCPCS codes L0648, L0650, L1832, L1833, and L1851 for the following criteria:
ST Modifier - This modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary.
For a comprehensive list of contract supplier locations in each CBA, see the Supplier Directory on the Medicare.gov website.
|Non-Contract Suppliers and Exceptions||
Non-Contract Supplier Exceptions Fact Sheets for practitioners/physicians, physical therapists, and occupational therapists.
Modifiers: Physicians/Practitioners and Physical and Occupational Therapists Only
|Repairs and Replacements Provided in CBA||Medicare allows for the repair of beneficiary owned items by any Medicare-enrolled supplier. Beneficiary owned competitively bid OTS back or knee braces that are replaced, rather than repaired, must be furnished by contract suppliers when beneficiaries obtain these items in a CBA. Refer to Repairs and Replacements of Off-the-Shelf Back and Knee Braces fact sheet on the CMS website.|
|Single Payment Amount||
Suppliers will find the Single Payment Amounts (SPAs) for the Healthcare Common Procedure Coding System (HCPCS) codes included in Round 2021 of the DMEPOS Competitive Bidding Program on the Competitive Bidding Program Contractor (CBIC) website. Existing payment amounts have been replaced with these SPAs for the selected HCPCS codes in certain competitive bidding areas (CBAs) when Round 2021 was implemented on January 1, 2021. For more information on how SPAs are calculated, please see the Lead Item Pricing fact sheet.
|Informational Flyer Regarding Round 2021 Off the Shelf (OTS) Back and Knee Braces||
The Centers for Medicare & Medicaid Services (CMS) released a printable flyer for referral agents, State Health Insurance Assistance Programs (SHIPs), suppliers, and other stakeholders to share with Medicare beneficiaries and other interested individuals. The flyer provides information regarding Round 2021 of the DMEPOS CBP and how to determine if a beneficiary is impacted by it. This flyer can be downloaded from the CBIC website.
|Round 2021 Off the Shelf (OTS) Back and Knee Braces||
On October 27, 2020, the Centers for Medicare & Medicaid Services (CMS) announced the single payment amounts for:
Round 2021 of the DMEPOS Competitive Bidding Program began on January 1, 2021 and extends through December 31, 2023. Round 2021 consolidates the competitive bidding areas (CBAs) that were included in Round 1 2017 and Round 2 Recompete. Round 2021 includes 130 CBAs.
OTS back braces HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651.
|Traveling Beneficiary - KT modifier||
The Traveling Beneficiary Fact Sheet is available on the Medicare Learning Network and provides guidance on the rules for traveling beneficiaries and the use of the KT modifier from January 1, 2021, thru December 31, 2023.
Effective for dates of service on or after July 1, 2021, we continue the KU modifier fee schedule amounts for wheelchair accessories (including seating systems) and seat and back cushions you provide for wheelchair codes E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0005 and K0008. We continue to pay for these items when you provide them for a complex rehabilitative or certain manual wheelchairs and bill them with the KU modifier. Continue to add the KU modifier when billing the manual wheelchair accessories and seat and back cushion codes listed in Attachment A of CR 12345.
- DMEPOS Competitive Bidding Program
- Competitive Bidding Implementation Contractor (CBIC) - Bidding and Contract Suppliers should use this website as their primary source of program information
Last Updated Tue, 21 Jun 2022 19:11:58 +0000
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