Reimbursement Issues

2022 Medicare Fee Schedule Update

The 2022 Medicare DMEPOS Fee Schedule was increased by a net total of 5.1% for claims with a date of service on or after January 1, 2022. The 5.1% increase is the result of a CPI-U increase of 5.4%  and a -0.3% productivity adjustment. You may download the 2022 DMEPOS Fee Schedule here.

Medicare Sequestration Suspension Extended

The suspension of the 2% sequestration-based reduction in Medicare reimbursement has been extend  through March 31, 2022 and then from April 1st through June 30, 2022 the sequestration-based reduction will be 1%

Face-to-Face & Written Order Prior to Delivery Requirements

On January 12, 2022 the Centers for Medicare and Medicaid Services (CMS ) announced that the following six O&P HCPCS codes will require a Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) as a condition of payment for claims with a date of service on or after April 13, 2022:

  • L0648 Lumbar-Sacral Orthosis, 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, Off-The-Shelf
  • L0650 Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), 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, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
  • L1832 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
  • L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
  • L1851 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, Off-The-Shelf
  • L3960 Shoulder Elbow Wrist Hand Orthosis, Abduction Positioning, Airplane Design, Prefabricated, Includes Fitting And Adjustment

Prior Authorization Expanded to Include Select Orthoses

On January 12, 2022 the Centers for Medicare and Medicaid Services (CMS ) added the following 5 O&P HCPCS codes to the list of codes that will require Medicare Prior Authorization:

  • L0648 Lumbar-Sacral Orthosis, 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, Off-The-Shelf
  • L0650 Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), 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, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
  • L1832 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
  • L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
  • L1851 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, Off-The-Shelf

Medicare prior authorization for these five codes will be implemented in three phases. Phase 1 includes New York, Illinois, Florida, and California and begins on April 13, 2022. Phase 2 adds Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington and begins on July 12, 2022. Phase 3 includes all remaining states and territories and begins on October 10, 2022.

 

Medicare Medical Policies

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Ankle-Foot/Knee-Ankle-Foot-Orthosis: LCD & Policy Article

Spinal Orthoses(TLSO and LSO): LCD & Policy Article

Knee Orthoses: LCD & Policy Article

External Breast Prostheses: LCD & Policy Article

Diabetic Shoes/Inserts: LCD & Policy Article

Orthopedic Shoes/Inserts: LCD & Policy Article

Standard Documentation Requirements: Local Coverage Article