Month: December 2017

The Centers for Medicare and Medicaid Services (CMS) has released the 2018 Medicare DMEPOS fee schedule which will be effective for Medicare claims with a date of service on or after January 1, 2018.  The 2018 Medicare fee schedule for orthotic and prosthetic services will be increased by 1.1% over 2017 rates. The 1.1% increase is a net reflection of the 1.6% increase in the Consumer Pricing Index for Urban Areas (CPI-U) from June 2016 through June 2017, combined with the annual Multi-Factor Productivity Adjustment (MFP) of -0.5%.

The 1.1% increase in the O&P Medicare fee schedule for 2018 represents a 0.4% larger amount than the 2017 increase of 0.7%.  Unfortunately, the 2% sequestration based reduction to all Medicare payments remains in effect (currently through 2025) meaning that Medicare fee for service payments will continue to be reduced by 2% due to sequestration.  While sequestration continues to impact Medicare reimbursement, it is not cumulative.  You will still receive 1.1% more for a service you provide in 2018 then you did in 2017 since the 2% sequestration reduction would be applied to both claims.

Download the complete 2018 Medicare DMEPOS fee schedule from the CMS website.

As always, AOPA maintains the most current Medicare fee schedule information and will be happy to provide it to AOPA members.

Questions regarding the 2018 Medicare fee schedule may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.

The October 16, 2017 Federal Register included a proposed rule published by the Department of Veterans Affairs (VA) that intends to “reorganize and update the current regulations related to prosthetic and rehabilitative items, primarily to clarify eligibility for prosthetic and other rehabilitative items and services, and to define the types of items and services available to eligible veterans.”

There is a provision in the proposed rule that significantly threatens longstanding VA policy that allows the veteran to decide whether they receive O&P services directly from the VA or from a VA contracted provider.  The proposed language states the following:

“VA will determine whether VA or a VA-authorized vendor will furnish authorized items and services under § 17.3230 to eligible veterans. When VA has the capacity or inventory, VA directly provides items and services to veterans. However, VA also may use, on a case-by case basis, VA authorized vendors to provide greater access, lower cost, and/or a wider range of items and services. We would clarify in regulation that this administrative business decision is made solely by VA to eliminate any possible confusion as to whether a veteran has a right to request items or services generally, or to request specific items or services from a provider other than VA, and to clarify for the benefit of VA-authorized vendors that VA retains this discretion as part of our duty to administer this program in a legally sufficient, fiscally responsible manner.”

This language, if finalized, is in direct conflict with the current VA policy as well as the Veteran’s Access, Choice, and Accountability Act of 2014 and will significantly restrict the ability of a veteran to see the VA contracted provider of their choice for prosthetic and orthotic care. AOPA submitted comments on the proposed rule which were due on December 15, 2017.  Read AOPA’s comments.

AOPA provided a portal for members to submit comments through AOPAvotes (now closed), which more than 250 members used.

AOPA has also published an ad in Politico, a newspaper of legislative and political news that is delivered to Congress and the White House, and read by think tanks, federal agencies, etc, seen below:

Questions regarding this issue may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.

On December 11, 2017, AOPA submitted formal comments on CMS’ proposed change to the DMEPOS Quality Standards that would expand the definition of the term “molded to patient model” to include custom fabricated diabetic inserts that are fabricated using a virtual or digital model of the patient’s foot and a direct milling process.  Earlier this year, the DME MACs published a correct coding bulletin that indicated that because direct milled inserts were not molded over a positive model of the patient’s foot, they could not be billed using HCPCS code A5513 and would have to be billed using A9270 which is a statutorily non-covered service.

The proposed change to the DMEPOS Quality Standards creates a pathway for Medicare coverage for direct milled inserts but a subsequent frequently asked questions (FAQ) document published by CMS indicates that direct milled inserts cannot be billed using A5513 and that reimbursement for inserts fabricated this way will be reduced by approximately 14%.

AOPA’s comments generally supported the proposed change to the DMEPOS Quality Standards but challenged the CMS proposal to arbitrarily reduce the reimbursement rate for direct milled inserts.  AOPA believes that the manner of fabrication is irrelevant and that the proposed change to the DMEPOS Quality Standards should allow direct milled inserts to be properly billed using A5513.

Read the comments.

Submit comments on the CMS proposed changes to the DMEPOS quality standards that would include a 14% reduction in reimbursement for custom fabricated, direct milled diabetic inserts. In July, the DME MACs released a clarification stating that diabetic inserts billed using A5513 must be molded over an actual model of the patient’s foot.  At that time, the DME MACs stated that the use of generic, electronic or “virtual” models where custom fabrication occurs without creation of a physical model of the patient’s foot did not meet the code descriptor for A5513.

AOPA has been in touch with CMS to voice our concern over this issue, and in September CMS proposed a change to the quality standards to allow for the use of digital or virtual models in combination with a direct milling process to meet the definition of “molded to patient model.”  However, in a FAQ document, CMS indicated that inserts that were fabricated using a direct milling process would be reimbursed approximately 14% lower than those that were molded over a physical model of the patient’s foot which takes a “toll” on providers who chose to provide direct milled inserts that are identical to inserts fabricated using the older technology of molding the insert over a model of the patient’s foot.

CMS has indicated that it intends to finalize the proposed changes by January 1, 2018, and is taking comments under December 11. AOPA has prepared comments that can be submitted on AOPAvotes.org.

Submit your comments now.