J5 - JA DME

DMEPOS item subject to DMEPOS Competitive Bidding Program that is furnished as part of a professional service by physical or occupational therapists

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.

1. Physical therapists and occupational therapists

From January 1, 2021, thru December 31, 2023, the CBP will only be in effect for OTS back and knee braces.

Correct Use

• Physical therapists and occupational therapists in private practice who are enrolled as Medicare DMEPOS suppliers have the option to furnish OTS back braces and OTS knee braces without being a competitive bidding contract supplier provided that the items are furnished only to the therapist’s own patients as part of the physical or occupational therapy service.
• To be paid for OTS back braces as a non-contract supplier, physical therapists and occupational therapists should use the modifier J5 in combination with the OTS back and knee braces.
  • 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 physical or occupational therapy service billed to the Part A/Part B MAC.
  • Physical therapists and occupational therapists are advised to submit the therapy claim and the OTS back brace or OTS knee brace claim on the same day to ensure timely and accurate claims processing

Resource

DMEPOS Competitive Bidding Program Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists MLN Fact Sheet