Noridian Healthcare Solutions, who serves as the Jurisdiction D DME MAC has recently released the results of its ongoing pre-payment review for spinal orthoses described by L0648 and L0650 and knee orthoses described by L1832 and L1843.
From January until April, 2015, 154 claims for L0648 were reviewed and 101 were denied representing an overall claim denial rate of 66%. In the same timeframe, 153 claims for L0650 were reviewed and 106 were denied representing an overall denial rate of 69%. The top reasons for denial were no documentation submitted, invalid proof of delivery, no dispensing or detailed written order, and no documentation supporting the need for replacement.
Based on the denial rates, Noridian will continue its pre-payment review for these codes.
From January until April 2015, 89 claims for L1832 were reviewed, all of which were denied representing an overall denial rate of 100%. In the same timeframe, 93 claims for L1843 were reviewed and 92 were denied for an overall denial rate of 99%. The top reasons for denial were no documentation submitted, lack of documentation supporting the medical need for a custom fitted device rather than an OTS device, no documentation of knee instability or ambulatory status of the beneficiary, and invalid proof of delivery. Based on the denial rates, Noridian will continue its pre-payment review for these codes.
AOPA’s take on the results of both of these pre-payment reviews is that the DME MACs are now actively enforcing the revised proof of delivery requirements published in February, 2015 as well as the policy requirement regarding the need to document the specific modifications that were made to a device in order to justify billing it as custom fitted. These are both recent, but significant changes to coverage policy and are actively contributing to higher claim denial rates during pre-payment reviews.
O&P providers must continue to be diligent in making sure that policy requirements are met, regardless of whether they or AOPA believe they are fair. Failure to comply with these policy changes will only contribute to higher error rates which in turn lead to additional pre-payment reviews.
AOPA’s Take, Where you go…..When you need to know!
An intensive, three month long advocacy effort by O&P professionals in New York state has lead to a significant victory through a reversal of policy in the New York State Healthcare Exchange benchmark plan that limited coverage for artificial limbs to one prosthesis, per limb, per lifetime. In a letter dated May 17, 2015, Donna Frescatore, the Executive Director of the New York State Health Exchange indicated that the benchmark plan will be altered, effective January 1, 2016 to include coverage of the cost of repairs to and replacement of artificial limbs for both children and adults covered by the plan.
This reversal of an overly restrictive and unfair policy that limited coverage to one prosthesis per limb, per lifetime was the direct result of the tireless advocacy efforts of O&P practitioners in New York, who received direct support in their efforts by the Amputee Coalition and the National Association for the Advancement of Orthotics and Prosthetics, as well as broad support from industry groups such as AOPA and the O&P Alliance. The coalition that challenged this policy was extremely well organized and sent a very powerful message to lawmakers and policymakers in New York who had the authority to make this change, that beneficiaries must be treated fairly and have reasonable access to exchange based healthcare benefits that are required under the Affordable Care Act.
AOPA’s Take on this victory is that it is a valuable lesson regarding the value of advocacy in today’s healthcare environment. The folks in New York recognized that the one limb per lifetime restriction was extremely detrimental to beneficiaries looking to the healthcare exchange to purchase adequate health insurance. they were able to mobilize an incredible advocacy campaign and effect change in a very short amount of time.
AOPA continues to support grassroots advocacy across the country and is encouraged by the victory in New York. The only way to create change is to make sure that your voice is heard.
AOPA’s Take. Where You Go…..When You Need to Know!!!
On May 13, 2015, the Centers for Medicare and Medicaid Services (CMS) announced the final award of the National Supplier Clearinghouse (NSC) contract to NCI Information Systems, Inc. a Reston, VA based IT firm that will administer the contract through AdvanceMed, a wholly owned subsidiary that also holds several CMS contracts to serve as regional Zone Program Integrity Contractors (ZPICS). The contract, worth $52 million, is for one base year and up to 4 additional option years.
Palmetto GBA, who has held the NSC contract since the creation of the NSC almost 20 years ago, filed a protest of the original contract award which was dismissed by the Government Accountability Office, clearing the way for the final award of the NSC contract to NCI.
CMS did not provide any specific information regarding when the transition of the NSC contract will occur. AOPA will provide any information regarding the transition as it is announced.
AOPA’s take on this issue is that this may be a bit of a bumpy road, especially in the beginning of the transition period. Theoretically, the transition should be seamless to the provider community but Palmetto GBA has had 20 years to refine their processes, which still remain far from perfect. NCI based its proposal on its ability to provide streamlined provider enrollment with increased focus on keeping questionable suppliers from enrolling in the Medicare program. While its proposal was successful, in terms of achieving the contract award, the transition to a new contractor always creates the potential for problems and delays in processes. While Palmetto GBA has been far from perfect, NCI is an unknown entity which creates a lot of uncertainty regarding their ability to improve on the processes developed by Palmetto GBA.
AOPA will continue to monitor this issue and communicate any updates as they are announced and implemented.
AOPA’s Take. Where you go……When you need to know!!
The four DME MACs have revised a joint coding bulletin regarding the proper coding of custom fitted prefabricated orthoses versus off the shelf (OTS) orthoses. The revised bulletin reiterates the need for “substantial modification by a qualified individual” when billing for a custom fitted orthosis as opposed to an off the shelf orthosis. This is nothing new and is simply a re-statement of what has been existing policy for several years. The revised bulletin does add a new twist however. It states that if a HCPCS code is identified as prefabricated but does not have a corresponding code that describes the same product delivered as an OTS orthosis, it can only be used to bill orthoses that are supported by documentation of substantial modification to the orthosis performed by an individual with expertise in fitting. If this documentation does not exist, or the substantial modification was performed by a person without expertise in fitting, the orthosis must be billed with the appropriate miscellaneous code (L1499, L2999, L3999) and the supplier must indicate that the orthosis was delivered as an OTS item in the narrative field on the claim form.
The Medicare LCDs for spinal orthoses, AFOs/KAFOs, and knee orthoses have all been updated, effective May 1, 2015, to incorporate the language of the revised coding bulletin.
AOPA’s take on this issue is that this “clarification” represents a major shift in policy regarding the proper coding of custom fitted orthoses. If you are providing a custom fitted orthosis and expect to receive reimbursement from Medicare, you must ensure that documentation supports not only the need for whatever modifications were required to obtain a proper fit of the device but that the modifications were performed by a certified orthotist or other medical professional that is deemed qualified to perform the modifications. Failure to do so may lead to unnecessary and costly claim denials.
A link to the revised coding bulletin published by the DME MACs may be found at the link below.
AOPA’s Take. Where you go……When you need to know!
On April 21, 2015, the Centers for Medicare and Medicaid Services (CMS) announced the product categories and Metropolitan Statistical Areas (MSAs) that will be included in the next round of DMEPOS Competitive Bidding, now being called Round 1 2017. While it appeared that off the shelf (OTS) orthoses were being considered for inclusion in competitive bidding, OTS orthoses were not among the eight product categories identified for inclusion in the Round 1 2017 competitive bidding program.
AOPA’s Take on this issue is that while this is certainly a positive development, it does not mean that OTS orthoses will not be included in competitive bidding at some point. The descriptor changes that were implemented in 2014 to clearly distinguish OTS orthoses from custom fitted orthoses certainly indicate the intent of CMS to eventually include OTS orthoses in competitive bidding at some point in the future.
AOPA will continue its ongoing discussion with CMS regarding its concern about the continued expansion of what are considered OTS orthoses through regulatory and policy based channels rather than following the appropriate notice and rulemaking process required by the Administrative Procedures Act.
AOPA’s Take. Where you go….When you need to know!
Last week, over 120 AOPA members came to Washington, D.C. to participate in the 2015 AOPA Policy Forum. This is the one time each year that AOPA members have the opportunity to join their colleagues and meet with their elected officials in Washington. Whether folks were participating for the first time or were seasoned veterans, the excitement in the air was palpable. AOPA’s message was strong and its members were ready to deliver it to their representatives and senators.
The two day program began with a “primer” day in which attendees heard from various speakers who offered hints on how to approach lawmakers and their staff regarding the issues at hand. Rep. Brett Guthrie (R-KY) addressed the audience as the keynote speaker for day 1 and discussed the importance of actively participating in the legislative process. Several other presentations and discussion panels prepared the attendees for their congressional visits scheduled for the next day.
Day two began with remarks from Sen Charles Grassley (R-IA) who stressed the importance of lawmaker visits and the impact that they have as well as his strong belief in the O&P Medicare Improvements Act, a bill which he proudly serves as co-sponsor of. After Senator Grassley’s remarks, participants received their schedules and headed off to meet with their legislators,
Feed back on the visits was extremely positive as most Policy forum participants indicated that the lawmakers and staffers they met with were receptive to AOPA’s message.
AOPA’s Take on the 2015 Policy Forum is that it was an extremely successful event that put AOPA members directly in touch with their congressional representatives. As Senator Grassley reminded the attendees, the 1st amendment does not only guarantee freedom of speech, but also guarantees the right to “petition for a governmental redress of grievances.” Participation in the AOPA Policy Forum allowed folks to exercise that right and bring AOPA’s message directly to Capitol Hill. If you have not yet participated in an AOPA Policy Forum, next years event will be here sooner rather than later. Active participation in your government is crucial to the success of your O&P practice.
AOPA’s Take. Where you go……when you need to know!
The results of recent Medicare audits of O&P claims bring a mixed message of relative success in some areas and continued deficiency in other areas. While improvements are always encouraging, the continued high error rates, specifically those involving claims for spinal orthoses indicate that there is still work to be done in understanding what Medicare expects and requires in order to reimburse O&P providers for legitimate services to Medicare beneficiaries.
The good news is found in recent audits results published by Jurisdiction B regarding its longstanding pre-payment review of high error rate DMEPOS claims. In the 4th quarter of 2014, Jurisdiction B reviewed a total of 5,893 claims of which 3,327 were denied, resulting in a claim error rate of 56.46%. While this error rate is still unacceptably high, it does continue the positive trend that has developed over the last year which began with a 68% claim error rate in the 1st quarter of 2014. Continued diligence by providers in making sure all of the documentation required for Medicare payment is contained in the patient’s medical record should drive the claim error rate increasingly lower with the hope that it is ultimately low enough to discontinue the pre-payment review.
The not so good news is the continued high claim error rates for spinal orthoses reported by both Jurisdiction B and Jurisdiction D. Jurisdiction B recently reported 4th quarter 2014 results that indicated a 95.80% error rate on spinal orthosis claims and Jurisdiction D reported a 4th quarter 2014 error rate of 99% for spinal orthosis claims. These high error rates clearly show that providers either do not understand the documentation requirements necessary for Medicare payment for these services or that the documentation requirements are so unreasonable that it is virtually impossible for providers to gather the necessary documentation to support the medical need for the spinal orthoses they are providing.
AOPA’s Take on this issue is mixed, just like the audit results. The continued downward trend of denials for high error rate services in Jurisdiction B is certainly encouraging but the error rates for spinal orthoses that are almost at 100% continues to be a source of frustration and confusion. We simply cannot be that bad when it comes to documentation for spinal orthoses.
AOPA encourages its members to review the LCD and Policy Article governing Medicare coverage of spinal orthoses and make sure that all of the documentation requirements are being met. especially the relatively new requirements that state that providers who bill for custom fitted orthoses instead of off the shelf orthoses document the specific modifications that were required to properly fit the orthosis to the patient.
AOPA will continue to monitor audit results published by the DME MACs and will continue to fight for the fair treatment of O&P providers.
AOPA’s Take. Where you go…..When you need to know!!!
AOPA has closely followed the issue surrounding what orthotic devices are considered to be “off the shelf” items that may be subject to Medicare competitive bidding as it has unfolded over the last several years. What began as a very small subset of HCPCS codes that represented truly off the shelf (OTS) orthotic devices that could reasonably be adjusted by the patient themselves, as stated in the law, and without any expertise from certified, trained professionals, has been repeatedly expanded through regulation and policies that are not consistent with the statute, to where we now have a set of more than 50 codes that CMS considers off the shelf, i.e., if they can be adjusted by the patient, caregiver for the patient, or by the provider of the device.
A significant development in this continuing expansion of what was considered OTS orthoses occurred when the DME MACs published revised medical policy that further defined the qualifications necessary to fit and provide custom fitted orthoses to Medicare beneficiaries. The medical policy was expanded to include the following definition of the term “substantial modification” as it relates to the provision of custom fitted orthoses.
“Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.”
This definition fails to recognize the scope of practice of certified orthotic fitters, whether certified by ABC or BOC, and their role in the provision of custom fitted orthoses, very typically working under the supervision of a certified orthotist. In addition, the definition that was published by the DME MACs was extracted essentially verbatim from a definition that was included in a CMS proposed rule (which when CMS published it in July, 2014 was intended to cover OTS, End-Stage Renal Disease and a range of other topics) in a DME MAC announcement before the open public comment period had concluded. Subsequently, CMS elected not to include anything relating to OTS orthotics in the final rule on several other topics that CMS ultimately published.
Despite repeated communications from AOPA and others challenging the authority of the DME MACs to memorialize this definition in policy before the proposed rule was finalized, and despite the fact that CMS chose not to include the proposed definition of “substantial modification” in its final rule, a CMS Frequently Asked Questions document that was updated on February 18, 2015, indicates that the policy guidance regarding who may provide custom fitted orthoses to Medicare beneficiaries remains in effect as the “DME MACs have discretion to define what constitutes custom fitting for accurate coding and payment of claims.”
AOPA’s Take on this issue is that this is yet another example of CMS’ inability or convenient refusal to exercise appropriate control over the actions of its contractors. The DME MACs have repeatedly established policy without regard to the Administrative Procedures Act requirement for due process through the issuance of proposed rules with appropriate opportunity for public comment and input followed by the issuance of a final rule. When AOPA has challenged the DME MACs or CMS regarding the lack of due process, the response has always been that the contractors are acting within the right to establish local policy to govern Medicare coverage of specific items and or services. AOPA believes that that a contractor hired by the government cannot have authorities greater than the Congress has delegated and articulated for the agency that hires the contractor. In this case, if CMS initiates a rulemaking to establish what constitutes an OTS orthotic device, and who may and may deliver custom fitted orthotics, the requirement that Congress imposed on CMS, namely that such rules may only be finalized after providing the opportunity for stakeholder input, cannot be circumvented by CMS claiming that these rules do not apply if the action or rules are advanced by a contractor CMS hires. AOPA will continue to challenge this policy specifically, and more generally instances of policy overreach by contractors acting under CMS’s authority at every opportunity.
AOPA’s Take. Where you go….when you need to know!
On February 12, 2015, the DME MACs released a joint article that discussed the proper format for proof of delivery documentation to support Medicare claims. The joint publication indicated that medical reviewers have consistently seen a list of HCPCS codes and their descriptors used on proof of delivery documentation, especially for orthotic and prosthetic claims.
According to the DME MACs, this practice is not acceptable for proof of delivery purposes as it does not allow the medical reviewer to make a determination of what was billed and if it was coded correctly. The joint DME MAC publication provides the following recommendation for maintaining proper proof of delivery documentation:
“The preferred method is use of a brand name and model number, brand name and serial number or manufacturer name and part number to identify the product. If this type of information is not available for the product, suppliers may use a detailed narrative description of the item; however, it must contain sufficient descriptive information to allow a proper coding determination. This “narrative description” of the item is not the HCPCS code narrative.”
AOPA’s Take on this issue is that this is yet another hurdle to reimbursement for providers who are providing medically necessary O&P care to Medicare beneficiaries. The documentation of HCPCS codes and their complete descriptors has been acceptable for proof of delivery purposes for many years. The sudden change in policy appears to be inconsistent with what is in the Program Integrity Manual and other CMS policy documents. AOPA will be communicating its concern regarding this policy change with the DME MACs and CMS,
AOPA’s Take. Where you go….When you need to know!
As I sat with my family this past Sunday and got ready to watch the Super Bowl with the rest of the world, I had no idea that my favorite highlight would have nothing to do with the game.
Like most viewers, I was excited to watch the action on the field but also looking forward to the creative and always entertaining commercials that receive so much hype leading up to the big game. With advertisers literally spending millions of dollars for 30 seconds of airtime, the most creative minds in the world are tasked with capturing the hearts of the audience for that one brief, shining moment.
This year, two different advertisers chose to use the inspiring stories of amputees as the backdrop for their Super Bowl ads. Microsoft featured young Braylon O’Neill in its ad for advanced analytic technology and Toyota featured Amy Purdy, a double amputee who gained fame on Dancing with the Stars, to showcase it’s newly remodeled Camry sedan.
AOPA’s take on these commercials is that while they were only 30 seconds long, the motivation of both Braylon and Amy to live life to the fullest despite the physical challenges they face shone through and sent an amazing message of inspiration and hope. I sat on the couch and beamed with pride knowing that I work for an industry that does so much for people, often because it is simply the right thing to do.
As folks get frustrated with continued scrutiny and audits by federal and private payers, it is easy to forget why most of you are in the business of O&P. You desire to help people with physical challenges return to a normal life. First and foremost, it is about the patients you serve. That is why I am so proud of what I do and the people I work for.
AOPA’s Take. Where You Go……When You Need to Know!