Month: November 2018

On November 13, 2018, the DME MACs published a revised Dear Physician letter that addresses the Medicare requirements for documentation within the referring physician’s medical records that support the medical necessity of orthotic and prosthetic services provided to Medicare beneficiaries.  This letter replaces an early Dear Physician letter, issued in August, 2011 that was retired earlier this year as a result of the passage of legislation which AOPA had promoted and lobbied for (Section 50402) that requires Medicare to consider the medical records of orthotists and prosthetists as a legitimate part of the medical record for purposes of claims payment and medical necessity review/determinations.

The newly released letter acknowledges the legislative change that was passed in February, 2018 and reminds physicians that while orthotist and prosthetists notes are now part of the patient’s medical record for purposes of medical necessity review, it emphasizes the continued need for referring physicians to document the medical need for the O&P devices they prescribe.  The letter stresses that O&P practitioner notes must “corroborate and provide details consistent with the physician’s records” and that conflicting information in the physician’s notes and O&P practitioner notes may result in claim denial.

The letter continues on to discuss the importance of physician documentation of the patient’s overall health to support their assigned functional level including symptoms limiting ambulation or dexterity, ambulatory assistance that the patient is using either in addition to their prosthesis or that they used prior to amputation, co-morbidities affecting ambulation and the ability to use a prosthesis, a summary of their activities of daily living, and a physical examination that is relevant to functional deficits.  AOPA is encouraged by the continued acknowledgement of a patient’s potential as a factor when establishing their appropriate functional level as well as the reminder that bilateral amputees cannot always be strictly bound by functional level classifications.

While the letter certainly is not perfect, AOPA is pleased that the DME MAC Medical Directors have acknowledged the legislative change that requires the recognition of O&P Practitioner notes as part of the medical record.  As AOPA has reported in the past, the legislative change does not and was not intended to remove or diminish the role of the physician as a vital partner in the rehab team. In this respect, the legislation generally puts things on documentation back to where they stood in July, 2011 (before that Dear Physician sought to completely eliminate all consideration of the O&P professional’s notes and records)—O&P clinical records are legitimate as consistent with, corroborative of, and fill in additional details in addition to the physician’s prescription and clinical findings submitted to CMS. This matches with the intent of the legislation to acknowledge and recognize the role of the O&P practitioner as a health professional with valuable clinical input on the overall health and prosthetic needs of the Medicare beneficiary.

AOPA is quite concerned by this latest Dear Physician letter’s assertion that prior and concurrent patient use of  ambulatory aids (canes, walkers, crutches and wheelchairs) as in any sense a significant consideration in determining a patient’s functional level,  This was a central tenet of the July 2015 proposed Local Coverage Determination which was universally criticized by all 80+ witnesses at the public hearing (also for lack of any scientific justification), and which was rejected earlier this year by the CMS Interagency Workgroup’s repudiation of that draft LCD, which also has since been ‘retired.’  Further, multiple scientific studies have shown that ambulatory aids are not necessarily an impediment to function and often improve a patient’s ability to effectively use a prosthesis.

AOPA will review the revised Dear Physician letter and provide any concerns that it has to the DME MAC Medical Directors, and other Medicare authorities.

The revised Dear Physician letter may be viewed here.

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

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) announced that it is soliciting comments on its proposed inclusion of off-the-shelf spinal orthoses and off-the-shelf knee orthoses as product categories in the next round of Medicare competitive bidding.  This announcement came on the same day that the final rule on changes to the competitive bidding program was announced. Ironically, a provision of the final rule was the announcement of a delay in the implementation of future rounds of competitive bidding until at least January 1, 2021.  While the impact of inclusion of OTS spinal and knee orthoses will not be felt for at least two years, the recent CMS announcement represents the first indication that OTS orthoses of any kind will be included in competitive bidding.

There is a total of 16 OTS spinal orthoses and 8 OTS knee orthoses that have been identified for inclusion in the competitive bidding program.  AOPA has performed preliminary analysis on the codes included in the proposal and traditional O&P providers are responsible for less than 15% of overall claims submitted to Medicare for the codes in question.  While these codes do not represent a large portion of a typical O&P practices business, AOPA continues to believe that no orthoses should be subject to competitive bidding and will be submitting comments to CMS indicating that competitive bidding for OTS orthoses is not in the best interest of patients or the Medicare program. The CMS announcement may be viewed here. Comments must be submitted by December 3, 2018.

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

The Centers for Medicare and Medicaid Services (CMS) has released the new Healthcare Common Procedure Coding System (HCPCS) codes for 2019, and there were 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, 2019.

New Codes

Changes in Code Descriptors

The change in the descriptor is a minor grammatical change, and not an actual change in the code verbiage. The new descriptor places parenthesis around the phrase or higher. The change makes the descriptor in line with the verbiage of the A5512 and the new A5514.

Deleted Codes

The temporary K code, K0903, which has been active since April 1, 2018 has been deleted and will be cross walked to the newly created A5514 code.

AOPA’s Coding and Reimbursement Committee will review the list of changes and provide appropriate comments to CMS.

As a reminder registration is still open for the December 12, 2018 AOPAversity webinar (New Codes, Medicare Changes & Updates), which will focus on the changes to the HCPCS code set and any other upcoming Medicare changes which may impact your business in 2019.

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

On November 1, 2018 the Centers for Medicare and Medicaid Services (CMS) published a final rule that addressed changes to the DMEPOS Competitive Bidding program and potential changes to the gap filling methodology that is currently used to establish Medicare fee schedules for new HCPCS codes.

The final rule followed a proposed rule that was published on July 11, 2018.  AOPA submitted comments on the proposed rule on September 10, 2018.  The competitive bidding and gap filling provisions addressed in the final rule are part of the larger final rule entitled, “Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) and Fee Schedule Amounts, and Technical Amendments to Correct Existing Regulations Related to the CBP for Certain DMEPOS”.  This is a rule that is published annually to update the Prospective Payment system for the Medicare prospective payment system for the Medicare End Stage Renal Disease program but has also been used to announce changes to the DMEPOS competitive bidding program.

The final rule confirmed that there will be at least a two year pause in the Medicare DMEPOS competitive bidding program while the provisions of the final rule are implemented, and new contract proposals are solicited and evaluated for award.  In the final rule, CMS does not expect the next round of competitive bidding to begin prior to January 1, 2021.

The provision of the proposed rule that is of greater immediate interest to AOPA members is one that requested input on improving the gap filling methodology that is currently used to establish Medicare fee schedule amounts for new HCPCS codes.  In the proposed rule, CMS announced that it was soliciting comments on how to improve the gap filling process.  In its comments, AOPA recommended that the gap filling process must be completely transparent and must be modernized to include accurate resources when establishing Medicare fees.  While CMS received significant comments on the gap filling process, it declined to initiate any changes to the gap filling process as part of the final rule.  The final rule only acknowledged the comments on the gap filling process and indicated that it would consider the recommendations that were submitted.

AOPA will continue to communicate with CMS regarding ways to improve the gap filling process and will report any changes to AOPA members.

On November 1, 2018, the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) released an updated Local Coverage Determination (LCD) for lower limb prostheses.  Since the changes to the LCD were minimal and do not restrict coverage, the notice and comment period required by the 21st Century Cures Act does not apply to this revision.

The only change to the LCD was the removal of the patient weight range (110 lbs to 275 lbs) for coverage of L5859–Addition to lower extremity prosthesis, endoskeletal knee shin system, powered and programmable flexion/extension assist control, includes any type motor(s).  All other requirements for coverage of L5859 remain the same.

AOPA continually reviews the Medicare LCDs and Policy Articles for changes such as this and will keep you informed when they occur.