DMEPOS item subject to DMEPOS Competitive Bidding Program that is furnished as part of a professional service

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. Physicians and other treating practitioners (physician assistants, nurse practitioners, and clinical nurse specialists);

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

Correct Use

• Medicare physicians, physician assistants, nurse practitioners, and clinical nurse specialists who are enrolled as Medicare DMEPOS suppliers 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.
• To be paid for OTS back braces as a non-contract supplier, physicians and other treating practitioners should use the modifier KV 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 professional service office visit billed to the Part A/Part B MAC.
  • Physicians and other treating practitioners 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

Resource

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