Important 2014 HCPCS Code/Competitive Bidding Update


To: AOPA Member Organizations

From: Joseph McTernan, AOPA Director of Reimbursement & Coding, Programming, and Education

Date: December 2nd, 2013

RE: 2014 HCPCS Code Update 

Important 2014 HCPCS Code/Competitive Bidding Update 

The Centers for Medicare and Medicaid Services (CMS) has released the 2014 HCPCS update.  This update includes all new, changed, and deleted HCPCS codes that will be implemented for claims with a date of service on or after January 1, 2014.  For codes that describe orthotic and prosthetic services, there are 24 new codes, 63 codes that have had their descriptors changed and 1 code that has been deleted.  This represents a significant number of changes in the O&P code set and represents a new reality for O&P providers specifically in relation to 23 services that have been split into two categories; orthoses that are provided “off the shelf” with no additional fitting and training, and those that are “customized to fit a specific patient by an individual with expertise.”
The August 2013 release of CMS’ final OTS list served as a clear indication of what was to come.  In this release, CMS provided responses to AOPA’s and other organizations concerns regarding the original OTS list.  The final list contained 32 codes that would always be considered OTS and proposed the split of 23 codes into off the shelf version and custom fit versions.  The creation of the split codes essentially sets the stage for CMS to include HCPCS codes which include the term “off the shelf” in their descriptors in a future round of competitive bidding.  AOPA has voiced its serious concerns regarding CMS’ expansion of the term “off the shelf” from the statutory definition which requires “minimal self adjustment” to include adjustments provided by the “beneficiary, caregiver, or supplier” through multiple meetings and correspondence with CMS officials.  Unfortunately, as indicated by the release of the 2014 HCPCS file, AOPAs concerns continue to fall on deaf ears.  While the potential for inclusion of OTS orthoses in future rounds of competitive bidding is obviously a major concern for the O&P profession, indications to date have been that it is not imminent and may be  months or possibly years away.
A larger concern, and one with potentially immediate impact, is how the split codes may affect O&P provider’s ability to bill and receive proper reimbursement for orthoses which require the expertise and professional training of an O&P professional in order to prevent potential harm to patients.  Essentially there are now two ways to deliver the 23 orthoses that have had their codes split; those provided without any fitting and training, and those that are customized to fit a specific patient by an individual with expertise.  The question that has now been created is who will make the decision whether an orthoses requires proper fitting by a trained individual or can be delivered as an off the shelf item without additional fitting and training?  AOPA members must be especially cognizant of the need to document the medical need for additional fitting and training as well as the actual time spent customizing the device to meet the individual needs of the patient.  The referring physician should also be encouraged to document the need for additional training and fitting as well.
AOPA will continue to press CMS for answers to the questions above and make sure that its member’s best interests are properly represented.
Below are links to several resources that provide additional information regarding the new and revised codes.  The November 2013 AOPA Executive Director letter, published prior to the release of the HCPCS file provides a thorough review of the potential impact of the code changes.  In addition, links to the AOPA summary of HCPCS additions, deletions, and changes, the August 2013 CMS final OTS list and comments, a letter to Laurence Wilson of CMS, and a brief overview of the potential impact of competitive bidding are included.
The upcoming AOPA Audio conference, scheduled for Wednesday, December 11, 2013 at 1 p.m. Eastern Time, will focus on the upcoming changes to the HCPCS codes and their potential impact on O&P providers. The cost of the call for AOPA members is just $99 for an unlimited number of participants per telephone line. 

Questions regarding this issue may be directed to Joe McTernan at  or Devon Bernard at .