2025 Medicare Fee Schedule Update
The 2025 Medicare DMEPOS Fee Schedule was increased by a net total of 2.4% for claims with a date of service on or after January 1, 2025. The 2.4% increase is the result of a CPI-U increase of 3.0% and a -0.6% productivity adjustment. You may download the 2025 DMEPOS Fee Schedule here.
CMS Names New RAC for Region 5
CMS has awarded a new contract for the Region 5 Recovery Audit Contractor (RAC). Region 5 handles RAC services for all DMEPOS claims. The new RAC will be Cotiviti GOV Services LLC. Performant, the RAC previously responsible for reviews in Region 5, remains under contract with CMS to support the RAC Program from an administrative and appeals perspective, while Cotiviti GOV Services LLC will soon start active reviews. Cotiviti GOV Services LLC will begin reviews in the Summer (2025). RAC Region 5 providers can rely on the review completion date specified in the review results letter, as well as the RAC’s name on the letter, to identify which contractor to reach for inquiries. If Performant receives inquiries regarding reviews conducted by Cotiviti GOV Services LLC, Performant customer service will inform providers to reach out to Cotiviti GOV Services LLC and Cotiviti GOV Services LLC will do the same.
CMS Expands its List of Codes Subject to Face-to-Face Encounters, Written Orders Prior to Delivery and Prior Authorization
On May 13, 2024, the Centers for Medicare and Medicaid Services (CMS) announced that the following six O&P HCPCS codes will require Medicare Prior Authorization nationwide for claims with a date of service on or after August 12, 2024:
- L0631- Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L0637- Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L0639- Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L1843- Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
- L1845- Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
- L1951- Ankle foot orthosis (AFO), spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment announced.
As a reminder the following O&P HCPCS codes already require prior authorization as a condition of payment: L0648, L0650, L1832, L1851, L5856, L5857, L5858, L5973, L5980, and L5987.
CMS also announced that the following eight O&P HCPCS codes will require a Face-to-Face Encounter and Written Order Prior to Delivery as a condition of payment for claims with a date of service on or after August 12, 2024:
- L0635- Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
- L0636- Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated
- L0638- Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated
- L0639- Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L0640- Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated
- L0651- Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf
- L1845- Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L1852- Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
As a reminder the following O&P HCPCS codes already require a Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) as a condition of payment: L0631, L0637, L0648, L0650, L1832, L1843, L1851, L1932, L1940, L1951, L1960, L1970, L2005, L2036 and L3960.
Lastly, CMS announced that the code L1833, (Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf), has been removed from the current list of codes requiring Prior Authorization, a Face-to-Face Encounter and Written Order Prior to Delivery as a condition of payment for claims with a date of service on or after August 12, 2024
Face-to-Face Encounter & Written Order Prior to Delivery (WOPD) Requirements
Please be reminded that the date of the WOPD must be on or before the date of delivery, and it must be completed within six (6) months after the required face-to-face encounter with the treating practitioner. The required elements of the WOPD are the exact same as a Standard Written Order (SWO).
With the face-to-face encounter (F2F) the treating physician or eligible provider must document and communicate to you that they had F2F encounter with the patient within the 6 months before the date on the written order/prescription. The F2F encounter can be an in-person or a valid telehealth visit. During the encounter the eligible provider must document subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which they order an O&P item. This documentation must be in the pertinent medical record and can include History, Physical examinations, Diagnostic tests, Summary of findings, Progress notes, Treatment plans, etc.