On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) announced that it is soliciting comments on its proposed inclusion of off-the-shelf spinal orthoses and off-the-shelf knee orthoses as product categories in the next round of Medicare competitive bidding. This announcement came on the same day that the final rule on changes to the competitive bidding program was announced. Ironically, a provision of the final rule was the announcement of a delay in the implementation of future rounds of competitive bidding until at least January 1, 2021. While the impact of inclusion of OTS spinal and knee orthoses will not be felt for at least two years, the recent CMS announcement represents the first indication that OTS orthoses of any kind will be included in competitive bidding.

There are a total of 16 OTS spinal orthoses and 8 OTS knee orthoses that have been identified for inclusion in the competitive bidding program. AOPA has performed preliminary analysis on the codes included in the proposal and traditional O&P providers are responsible for less than 15{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} of overall claims submitted to Medicare for the codes in question. While these codes do not represent a large portion of a typical O&P practices business, AOPA continues to believe that no orthoses should be subject to competitive bidding and will be submitting comments to CMS indicating that competitive bidding for OTS orthoses is not in the best interest of patients or the Medicare program.

The CMS announcement may be viewed here.

Comments must be submitted by December 3, 2018.

Questions regarding this issue may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.

AOPA’s Take.  Where You Go……When You Need to Know!!!

On November 1, 2018, the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) released an updated Local Coverage Determination (LCD) for lower limb prostheses. Since the changes to the LCD were minimal and do not restrict coverage, the notice and comment period required by the 21st Century Cures Act does not apply to this revision.

The only change to the LCD was the removal of the patient weight range (110 lbs to 275 lbs) for coverage of L5859–Addition to lower extremity prosthesis, endoskeletal knee shin system, powered and programmable flexion/extension assist control, includes any type motor(s). All other requirements for coverage of L5859 remain the same.

AOPA continually reviews the Medicare LCDs and Policy Articles for changes such as this and will keep you informed when they occur.

AOPA’s Take. Where You Go……..When You Need to Know!