Round 2021, will be the first round of Medicare competitive bidding using the newly implemented lead item pricing methodology. Within each of the selected product categories, a single lead item (the item with the highest total allowed charges nationwide) has been identified for bidding purposes, and under this methodology, CMS establishes the single payment amounts (SPAs) for competitive bidding items based on maximum winning bid amounts for the lead item in each product category.
Suppliers will submit one composite bid for each code/OTS brace representing the lead item in the product category. The supplier’s bid for the lead item represents its bid for furnishing not only the lead item but all the items in the product category as a whole. Winning suppliers are responsible for furnishing all items in the product category for which they are submitting bids, and each supplier’s bid for the lead item is a bid for furnishing all items in the product category.
The Round 2021 lead items for the selected O&P product categories are:
- 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
- L1833- Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
Any bid amount for each lead item must be at or below the 2019 unadjusted fee schedule amount for the state in which the competitive bidding area (CBA) is located, the bid limit. View the current bid limits in each state for the L0650 and the L1833.
Bids for the lead item in the product category will be used to calculate the SPAs for all the items within that product category. The SPA for the lead item is the maximum bid submitted for that item by suppliers whose bids for the item are in the winning range in that competitive bidding area and product category combination. The SPAs for all other HCPCS codes within the product category, the non-lead items, are determined by multiplying the lead item SPA by a relative ratio (based on the historic differences in the fee schedule amounts for the lead item and non-lead items). Here is the formula used to calculate the ratio:
The “historic unadjusted fee schedule amounts” is the updated historic fee schedule amount without any reductions based on competitive bidding information for DMEPOS that would be 2015.
Download the bid calculator worksheet to determine how your possible bid would affect your SPA.