Competitive Bidding - JD 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.
Round 2021
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.
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.
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.
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
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 | 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 | 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
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 Example: L1833ST |
EXCEPTION Modifier Physicians/Practitioners Providing Brace in a CBA Under Non-Contract Supplier Exception Example: L1833KV |
EXCEPTION Modifier OT/PT Providing Brace in a CBA Under Non-Contract Supplier Exception Example: L1833J5 |
---|---|---|---|
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 |
---|---|
Beneficiary in Competitive Bid Area |
|
Contract Suppliers |
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-Contracted Suppliers
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 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 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.
|
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 |
|
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
Last Updated Fri, 04 Aug 2023 19:56:09 +0000