Orthotics codes become trickier to bill

Friday, January 3, 2014

BALTIMORE – The 2014 Medicare DMEPOS fee schedule could create billing confusion for orthotics providers.

The recently released schedule applies the same payment amounts to 23 orthotics codes, regardless of whether they are classified as off-the-shelf (OTS) orthotics or require some customization.

“There is no difference in the reimbursement, but they do make a distinction in the description of the code,” said Ryan Ball, director of state policy for VGM & Associates. “Whether you just pull it off the shelf and give it to somebody, or if there’s trimming and bending and other customization, you have to note that.”

In September, CMS released a final list of what it considers to be OTS orthotics, which are defined as any items that can be used by the patient with minimal self-adjustment. Custom devices, on the other hand, must be provided by certified fitters, and require more clinical—and more expensive—care.

The question now becomes: Who will make the decision whether orthoses require proper fitting by a trained individual or can be delivered as an off-the-shelf item without additional fitting and training?

“The split codes may affect a provider’s ability to bill and receive proper reimbursement for orthoses that require the expertise and professional training of an O&P professional to prevent harm to the patients,” said Wendy Miller, director of facility accreditation for BOC.

Also, with two groups of very different products with the same reimbursement, Miller is concerned that providers will be at greater risk for audits.

“BOC encourages providers to do due diligence and document the medical need for additional fitting and training, as well as the actual time spent customizing the device,” she said.

There is pressure for CMS to differentiate the payment amounts for OTS vs. custom-fitted orthotics. The Office of Inspector General (OIG), for example, asked CMS to modify the amounts for OTS orthotics back in 2012.

“The OIG has specifically stated that if there wasn’t clinical care provided or any customization by a qualified individual, why was the payment for those services being included?” said Fise, executive director of the American Orthotics and Prosthetics Association. “CMS was asked to either modify the fee through inherent reasonableness, or if this puts us on the pathway to competitive bidding, then there’s a lot to be concerned about.”


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