Competitive Bidding - JD DME
DMEPOS Competitive Bidding Program
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.
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 |
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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) |
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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 |
Tips
Topic | Details |
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Beneficiary in Competitive Bid Area |
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Billing for Orthotics Requiring Prior Authorization in Acute Situations and Under Competitive Bidding |
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 for DME suppliers providing the codes above requiring prior authorization in an acute/emergent situation where a two-business day expedited review would delay care and risk the health or life of the beneficiary. Claims will be subject to 100% prepay review.
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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 |
Non-contracted suppliers submitting claims for beneficiaries that reside in a CBA and do not meet the definition of a traveling beneficiary, will need to obtain a properly executed ABN for off-the-shelf (OTS) back and knee braces. Suppliers that provide off-the-shelf (OTS) back and knees braces without a properly executed ABN cannot collect payment from the beneficiary.
Modifiers: Physicians/Practitioners and Physical and Occupational Therapists Only
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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 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 |
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 |
Round 2021 of the DMEPOS Competitive Bidding Program begins 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. |
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.
The HCPCS codes used to bill for OTS back braces: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651. |
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
- CMS Change Request (CR)9059 - Use of Modifiers KK, KG, KU, and KW under the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program
Last Updated Wed, 18 May 2022 14:42:14 +0000
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