Year: 2017

The Centers for Medicare and Medicaid Services (CMS) has released the new HCPCS codes for 2018, and there were only a few minor changes. Below is a complete breakdown of the code changes which will be effective for claims with a date of service on or after January 1, 2018.

 New Codes 

Changes in Code Descriptors 

As a reminder registration is still open for the December 13, 2017 AOPAversity webinar, New Codes & Other Updates for 2018, which will focus on the changes to the HCPCS code set and any other upcoming Medicare changes which may impact your business in 2018. AOPA’s Coding and Reimbursement Committee will review the list of changes and provide appropriate comments to CMS.

Questions regarding the code changes may be directed to Joe McTernan at jmcternan@aopanet.org, or Devon Bernard at dbernard@aopanet.org.

AOPA is pleased to announce that the Centers for Medicare and Medicaid Services (CMS) has proposed a change to the DMEPOS Quality Standards that addresses AOPA’s concern regarding the recent DME MAC/PDAC interpretation of the term “molded to patient model” when used to describe custom fabricated diabetic shoe inserts.  The proposed change to the quality standards allows for the creation of a digital positive model of the patient’s foot using CAD/CAM technology that is then used to direct mill a custom fabricated insert based on the digital model.

In July, 2017, the DME MACs and PDAC issued a joint bulletin that stated that in order to meet the definition of “molded to patient model” contained in the descriptor for A5513, diabetic inserts must be fabricated over a physical model of the patient’s foot.  The bulletin went on to state that digital or virtual models that were used to direct mill custom inserts are not considered a positive model and inserts fabricated using this technique do not meet the code requirements of A5513 and therefore must be billed as A9270, a statutorily non-covered HCPCS code.  On September 28, 2017, AOPA and the American Podiatric Medical Association (APMA) submitted a joint letter to CMS expressing their concern over this bulletin as it represented a significant threat to the use of advanced technology to provide better clinical service.  In addition to working directly with the APMA, AOPA worked closely with the O&P Alliance, Representative Wenstrup’s (R-OH) office, his staff, and the House VA Subcommittee on Health to make sure that this issue remained at the forefront of the discussion.

On November 2, 2017, CMS announced a proposed change to the DMEPOS Quality standards that would include the use of digital or virtual models to direct mill custom diabetic inserts as an acceptable method to meet the definition of “molded to patient model” contained in the code language for A5513.  CMS will hold an Open Door Forum call on November 28, 2017 at 2:00 pm EST to allow experts to discuss the proposed changes to the DMEPOS Quality Standards and will accept comments on the proposed changes through December 11, 2017.  Comments on the proposed changes may be sent to CMS via e-mail at ReducingProviderBurden@cms.hhs.gov.  CMS has indicated that it intends to finalize the proposed changes by January 1, 2018.

AOPA will participate in the Open Door Forum call and will be preparing comments for submission to CMS.

Review the proposed changes.

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.  This provision requires an immediate and powerful response.  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 has established a convenient pathway that will allow you to quickly express your concern regarding the VA proposed rule.  Simply visit www.AOPAVotes.org, enter some basic information, and a customized letter will be generated and sent to the VA to express your concern over the unnecessary and unreasonable provisions of the proposed rule. Send comments now.

• 92 studies were identified that assessed performance characteristics of lower limb prostheses
• 29 of the 92 studies were deemed valid and reliable by the researchers
• 19 of the 29 studies were generally applicable to Medicare aged populations
• 11-22% of amputees abandon their lower limb prosthesis within one year of delivery
• Unilateral trans-femoral amputees are twice as likely to abandon their prosthesis than unilateral trans-tibial amputees
• Currently, there is not evidence to support the selection of specific components for patient subgroups to maximize ambulation, function, and quality of life or to minimize abandonment or limited use

On October 19, AOPA hosted a press event at the National Press Club in Washington DC, to share the important research from the RAND Corporation on the economic value of advanced prosthetics.

Dr. Soren Mattke from RAND presented the findings of this recently published research that concluded that microprocessor knees are associated with improvements in physical function and reductions in falls and osteoarthritis, and that the economic benefits are in line with commonly accepted criteria for good value for money by U.S. payers.

Dr. Ken Kaufman, PhD of the Mayo Clinic, shared his research on health outcomes for those living with limb loss, including the cost of care broken down by K-level, and the costs of falls, and the large number of amputees who never receive a prescription for a prosthesis. Prosthetic users Christopher Allen and Peggy Chenoweth discussed how they have benefited from advanced technology in their everyday lives.

The video was livestreamed on Facebook and is now available to view. The Power Point presentations used are available upon request.

About the RAND Corporation study 
Due to recent advances in technologies, prosthetic knees allow for more-dynamic movements and improve user quality of life, but payers question their value for money. To explore this issue, RAND simulated the differential clinical outcomes and costs of microprocessor-controlled knees (MPKs) compared with non-MPKs (NMPKs). They conducted a literature review of the clinical and economic impacts of prosthetic knees, convened technical expert panel meetings, and implemented a simulation model over a ten-year time period for unilateral transfemoral Medicare amputees with Medicare Functional Classification Levels of 3 and 4.

They found that compared with NMPKs, MPKs are associated with sizeable improvements in physical function and reductions in incidences of falls and osteoarthritis. The simulation results show that over a ten-year time period, compared with NMPKs, MPKs are associated with an incremental cost of $10,604 per person and an increase of 0.91 quality-adjusted life years per person, resulting in an incremental cost of $11,606 per quality-adjusted life year gained. The results suggest that the economic benefits of MPKs are in line with commonly accepted criteria for good value for money and with those of other medical devices that are currently covered by U.S. payers.

Read the RAND Study.

This study is just part of AOPA’s commitment to advancing O&P research. See all of AOPA’s Research Initiatives.

Press about the Event so far:

O&P Edge– RAND Study: Far Fewer Falls With MPKS
Medscape– Modern Prosthetic Knees Cut Falls, Morbidity, Mortality in Amputees (login required)
Rehab Management – Amputees Are Being Denied Access to Higher-Tech Prostheses, Resulting in Preventable Injury and Death, Per RAND Study
NJTV PBS – Prosthetics tech gap costs money and lives according to report
Healthcare Business Daily News- Payors less inclined to cover high-tech prosthetics for amputees

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.  While the 48 page proposed rule will require some time to be reviewed completely, there is a provision in the proposed rule that is of immediate concern to AOPA.

Page 29 of the proposed rule includes a provision regarding how prosthetic, orthotic, and other rehabilitative services will be delivered to veterans.  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, will significantly restrict the ability of a veteran to see the VA contracted provider of their choice for prosthetic and orthotic care and must be addressed immediately.  AOPA, its Board of Directors, and its VA Committee are reviewing this proposed change in VA policy, which appears to be almost completely contrary to longstanding VA policy regarding veteran provider choice and the intent of the Veteran’s Access, Choice, and Accountability Act of 2014 which empowered Veterans to take a more active role in assuring their ability to receive convenient and timely care, whether through the VA directly or through the private sector.

Anticipating an AOPA position in opposition to this proposal, look for instructions as to how AOPA members can engage and mobilize patients on this important new proposed direction for prosthetic and orthotic care for Veterans.

The full text of the proposed rule may be viewed by clicking VA Proposed Rule

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On October 12, President Trump undertook a non-legislative overhaul of the country’s healthcare insurance program, and some significant administrative ‘repeal’ of the Affordable Care Act. Two major executive actions comprise this effort:

(1) clearing the path for sale of “short-term” insurance plans that do not have full ACA essential health benefits and other rules, at lower rates for healthy individuals, as well as clearing the path for sale of insurance through ‘association plans’ that will include sale of insurance across rate lines without meeting state license laws (parity laws from one state may not apply to plans sold by an out-of-state carrier who operates in a state that does not have parity rules). At peak, there were only about 100,000 Americans enrolled in these short-term plans, so immediate effect will probably not be dramatic. That said, this does initiate a segmenting of the market, incentivizing some healthy persons not to participate in the state-level insurance exchanges under ACA, but to gravitate to these cheaper, less robust short-term plans. If this snowballed to having much larger number of people in short-term plans it would tend to shift the risk pool in the exchanges in the direction of the unhealthier Americans, likely de facto giving them some characteristics of higher risk pools. Indirectly, persons with pre-existing conditions could find themselves relegated to the exchanges and their insurance rates would probably increase across the board without the balance of exchange participation by healthier individuals.

(2) The administration will stop providing the $7 billion in annual, so-called CSR subsidies to health insurers to help cover the co-pays and deductibles of lower income individuals. This is facilitated because of legal challenges where one federal district court deemed these subsidies illegal. Ending the subsidies creates some hard decisions for insurers. They may: (1) continue the credits for co-pays/deductibles without collecting any off-setting subsidy payments which would result in little change in policyholder experience in the short run (some insurers already issued major hikes in 2018 rates, likely anticipating that the subsidy payments would end); (2) thirty-two states will allow insurers to levy a surcharge to offset the loss of subsidies and thereby increasing the premiums (low cost insureds will be eligible for larger tax credits essentially offsetting these larger premiums so they won’t have too much pressing them to drop coverage), or (3) with subsidies unavailable, insurers are permitted to withdraw from the 2018 ACA insurance exchanges in each state over the next few weeks before annual enrollment in the ACA plans begins.

There is a timing disconnect. It will take a substantial amount of time for folks at HHS and CMS to write and implement the many new rules that will be needed to effectuate the short-term plans and association plans. So, these short-term plans will probably not be available for months or perhaps up to a year, even as the subsidy situation could push many folks from their current plans. Providers will want to take more special care that patients are enrolled and paid in their plans before delivering care. It’s important to recognize that, at least in the near term, these changes will impact only a portion of the health insurance market. In the short term; employer-based plans, Medicare, Medicaid, and VA, will remain unaffected—though in the longer term the premiums for these plans may change.

There are likely to be lawsuits challenging both of these steps. Both hospitals and health insurers will oppose these steps—hospitals because it will shift many more uninsured folks into emergency rooms, and increase uncompensated care (the expense of which falls on the hospitals), and insurers because, obviously, they want the subsidies. Look for attempts at legislation to stabilize insurance premiums.

Clearly, a time of change has been initiated that will impact providers over coming months. Depending on how health insurers respond, the results could have our health care looking more like it did before the ACA was enacted: more lower income people uninsured; sicker people potentially paying higher premiums, no assured universal essential health benefits, more people seeking care in hospital emergency rooms listed as uncompensated care, but actually with the cost of their coverage subsidized by higher costs for paying patients and cost-shifting. Can the President do this on his own? We will need to wait through a few years and watch the results on a likely bevy of litigation that will begin to unfold. One enduring fact will be that so long as the Affordable Care Act remains the law, any executive actions taken and regulations enacted by one President will be subject to the prospect of complete reversal by another President.

Stay tuned for what may be a somewhat turbulent ride. We’ll continue to keep AOPA members informed of significant developments.
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October 13, 2017