Reimbursement Issues


 Post Payment Review for Knee Orthoses

CGS and Noridian will be conducting widespread post-payment reviews for two knee orthoses: L1833 and L851.

 Post Payment Review for L0650

CGS, the DME MAC for Jurisdictions B & C, has just announced that they will be conducting a complex post-payment review for L0650, an off-the-shelf LSO. The review will be for claims with dates of service prior to March 1, 2020. If you receive additional documentation requests  as part of this review be sure to respond to them, however  be advised that CMS has implied that the DME MACs may allow for flexibility with extensions and the cancelling of audits based on individual supplier’s ability to complete the audit.  For more information view the announcement.

CMS Announces the Resumption of Medicare Audits

The Centers for Medicare and Medicaid Services (CMS) has authorized its Medicare contractors (e.g. DME MACs, RACS, SMRCs, etc.) to once again perform pre-payment and post-payment audits as part of their medical review responsibilities, startin on August 3, 2020.  CMS had suspended most audits as of March 30, 2020 due to the COVID-19 Public Health Emergency (PHE).  CMS indicates that if individual providers are selected for medical review believe that responding to a request for documentation will create a hardship situation, they should discuss response options with the contractor performing the review. Click here for more information.

New Standard Written Order (SWO) Requirements

The Centers for Medicare and Medicaid Services (CMS)  announced a significant change to the requirements for physician orders for Durable Medical Equipment, Orthotics, Prosthetics, and Supplies (DMEPOS).  The change is effective for claims with a date of service on or after January 1, 2020 and eliminates the need for an initial/dispensing order for Medicare DMEPOS services. Read about the SWO.

2020 Medicare Fee Schedule Update

The Centers for Medicare and Medicaid Services (CMS) has released the 2020 Medicare DMEPOS fee schedule which will be effective for Medicare claims with a date of service on or after January 1, 2020.  The 2020 Medicare fee schedule for orthotic and prosthetic services will be increased by 0.9% over 2019 rates. The 0.9% increase is a net reflection of the 1.6% increase in the Consumer Pricing Index for Urban Areas (CPI-U) from June 2018 through June 2019, combined with the annual Multi-Factor Productivity Adjustment (MFP) of -0.7% . Click here to view and download the complete 2020 Medicare DMEPOS fee schedule

Medicare Medical Policy Revisions & Updates

Lower Limb Prostheses
The Policy Article has been revised to include new coding guidelines and PDAC coding verification requirements. View the Policy Article

Ankle-Foot/Knee-Ankle-Foot-Orthosis
The Policy Article has been revised to include new coding guidelines for 16 AFOs. View the Policy Article. 

Spinal Orthoses: TLSO and LSO
There are no changes to policy at this time. View this policy

Knee Orthosis
There are no changes to policy at this time. View this policy

External Breast Prostheses
There are no changes to policy at this time. View this policy

Diabetic Shoes/Inserts
There are no changes to policy at this time. View this policy

Orthopedic Shoes/Inserts
There are no changes to policy at this time. View this policy