Competitive Bidding - JA DME
DMEPOS Competitive Bidding Program
DMEPOS Competitive Bidding Program: Temporary Gap Period
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 (CMS) 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.
Process Change
For dates of service beginning January 1, 2024, and after, there is a temporary gap period in the DMEPOS Competitive Bidding Program (CBP) for off-the-shelf back and knee braces. During the gap period, the prior authorization requirements for HCPCS codes L0648, L0650, L1833, and L1851 change and the competitive bid modifiers KV, J4, and J5 are no longer used. Treating practitioners now have the option to follow the prior authorization process with the standard timeframe of review, request an expedited review, or utilize the ST modifier, indicating acute/emergent need. For more information, refer to the Timeline and Updates section of the Prior Authorization and Pre-Claim Review Initiatives webpage on the CMS website. This process change only affects non-contract competitive bid suppliers who are practitioners/physicians, physical therapists, and occupational therapists.
Round 2021
Round 2021 of the DMEPOS Competitive Bidding Program began on January 1, 2021 and ended December 31, 2023. Round 2021 consolidated the competitive bidding areas (CBAs) that were included in Round 1 2017 and Round 2 Recompete. Round 2021 included 130 CBAs.
OTS back braces HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651.
OTS knee braces HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852.
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.
Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
- Required for codes: L1832, L1833, L1851, L0648, and L0650
- Effective 04/13/22
- Required for codes: L0631, L0637, L1843, L1932, L1940, L1951, L1960, L1970, L2005, L2036
- Effective 4/17/23
Prior Authorization Required for Orthoses
- Required for codes: L1832, L1833, L1851, L0648, and L0650
- Effective nationwide 10/10/22
Prior Authorization Timelines
Policy | Review Decision Timeframe | Expedited Review Decision Timeframe | PAR Decision Valid |
---|---|---|---|
Orthoses | 5 business days | 2 business days | 60 days |
Competitive Bid 2021 Modifier Chart - OTS Knee and Back Braces
Gap Period begins for DOS and after January 1, 2024.
Policy vs Competitive Bid Modifiers | Contract Supplier | Non-Contract Supplier | Non-Contract Suppliers Exceptions Physicians/Practitioners who are DME Suppliers |
Non-Contract Suppliers Exceptions Physical and Occupational Therapists who are DME Suppliers |
---|---|---|---|---|
Modifiers per Policy | Knee - KX, RT, LT Back - CG only when applicable |
Knee - KX, RT, LT Back - CG only when applicable |
Knee - KX, RT, LT Back - CG only when applicable |
Knee - KX, RT, LT Back - CG only when applicable |
Modifiers for Competitive Bid (Only valid through DOS 12/31/2023) | KT when applicable | KT when applicable | KV | J5 |
Non-Contract Suppliers Exception for Physician/Practitioner or Occupational Therapist (OT)/Physical Therapist (PT) Modifiers Situations
Modifier (Only valid through DOS 12/31/2023) | 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 |
Situations to Bypass Prior Authorization (Prior to DOS 1/1/2024)
In certain situations, there are special modifiers that will cause the claim to bypass prior authorization when billing a claim. These claims will be subject to prepayment review.
- All Medicare physicians or other treating practitioners IN a Competitive Bid Area (CBA), who are not a CB contracted supplier providing a brace in an acute or emergent situation who are enrolled as Medicare DMEPOS suppliers must append the KV or J5 modifier to the claim
- Practitioners and physicians must append KV modifier to claim line in these circumstances
- Occupational therapists (OT)/physical therapists (PT) must append J5 modifier to claim line in these circumstances
Refer to chart below for modifier requirements when bypassing prior authorization
HCPCS Code Requiring Prior Authorization | Modifier Acute/Emergent Situations for All DME Suppliers (Valid DOS 1/1/2024 and after) |
EXCEPTION Modifier Physicians/Practitioners Providing Brace in a CBA Under Non-Contract Supplier Exception (Only valid through DOS 12/31/2023) |
EXCEPTION Modifier OT/PT Providing Brace in a CBA Under Non-Contract Supplier Exception (Only valid through DOS 12/31/2023) |
---|---|---|---|
L1833 | ST | KV | J5 |
L1851 | ST | KV | J5 |
L0648 | ST | KV | J5 |
L0650 | ST | KV | J5 |
Note: More information about Non-Contract Supplier Exceptions in Tips section below
Tips
Topic | Details |
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Beneficiary in Competitive Bid Area |
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Contract Suppliers |
For a comprehensive list of contract supplier locations in each CBA, see the Supplier Directory on the Medicare.gov website.
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Non-Contract Suppliers and Exceptions (Gap period begins 1/1/2024) |
Non-Contracted Suppliers (Below only valid through 12/31/2023)
Non-Contract Supplier Exceptions Fact Sheets for practitioners/physicians, physical therapists, and occupational therapists.
Modifiers: Physicians/Practitioners and Physical and Occupational Therapists Only
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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. |
Former Competitive Bidding Area (CBA) Fee Schedule | Adjusted fees for former Competitive Bidding Areas (CBAs) during a gap period in the DMEPOS Competitive Bidding Program (CBP) are determined by CMS. These items have been paid based on the Former CBA Fee Schedules since 2019 (see MM11064). To view the Former CBA Fee Schedule, visit theCMS DMEPOS Fee Schedule page
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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 CBAs when Round 2021 was implemented on January 1, 2021. Resource - Round 2021 - DMEPOS CBP |
Round 2021 Off the Shelf (OTS) Back and Knee Braces (Gap period begins 1/1/2024) |
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 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 (Gap period begins 1/1/2024) |
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.
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KU Modifier MM12345 |
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. |
Modifiers |
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Resources
- DMEPOS Competitive Bidding Program
- Competitive Bidding Implementation Contractor (CBIC) - Bidding and contract suppliers should use this website as their primary source of program information