CMS issued CR 12282 to communicate the addition of HCPCS codes that require the use of a licensed/certified orthotist or prosthetist for furnishing custom fabricated and prefabricated (custom fitted) orthoses.
This change will apply to dates of service on or after October 1, 2021.
CMS regulations require Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers to operate their business and furnish Medicare-covered items in compliance with all applicable federal and state licensure and regulatory requirements.
Effective October 1, 2021, CMS will implement new claims edits to determine that the appropriate personnel is providing custom fabricated or prefabricated (custom fitted) orthotics in certain states. Claims for items furnished by personnel who are not licensed/certified orthotists or prosthetists by the state in which they practice will be denied.
There are 17 states currently requiring a licensed/certified orthotist or prosthetist to furnish orthotics or prosthetics. These states are: Alabama, Arkansas, Florida, Georgia, Illinois, Iowa, Kentucky, Mississippi, New Jersey, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, and Washington.
In these 17 states where a licensed/certified orthotist or prosthetist must provide prosthetics and orthotics, suppliers can only bill Medicare for prosthetics and certain custom-fabricated orthotics when physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel, and prosthetics personnel furnish them.
Suppliers need to ensure this information is reported to the National Supplier Clearinghouse (NSC) and submit applicable licenses or certifications.
The following specialties shall bill for Medicare services when state law permits such entity to furnish a prosthetic or orthotic item:
- Medical Supply Company with Orthotics Personnel – Specialty Code 51
- Medical Supply Company with Prosthetics Personnel – Specialty Code 52
- Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53
- Orthotics Personnel – Specialty Code 55
- Prosthetics Personnel – Specialty Code 56
- Orthotics Personnel, Prosthetics Personnel, and Pedorthists – Specialty Code 57
- Physical Therapist – Specialty Code 65
- Occupational Therapist – Specialty Code 67
- Pedorthic Personnel – Specialty Code B2
- Medical Supply Company with Pedorthic Personnel – Specialty Code B3
- Ocularist – Specialty Code B5
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