Full Replacement of CR3607, Payment Edits in Applicable States for DMEPOS Suppliers of Prosthetics and Certain Custom-Fabricated Orthotics; CR 3607 is Rescinded (O&P) Posted August 30, 2005
Medlearn Matters Number: MM3959 Related Change Request (CR) #: 3959 Related CR Release Date: August 19, 2005 Related CR Transmittal #: 656 Effective Date: October 1, 2005
Implementation Date: October 3, 2005
The following information affects physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel, and prosthetics personnel in Alabama, Florida, Illinois, New Jersey, Ohio, Oklahoma, Rhode Island, Texas, or Washington who provide or supply prosthetics and orthotics (P&O) and bill Medicare durable medical equipment regional carriers (DMERCs).
Provider Action Needed
Impact to You If you are an affected supplier in Alabama, Florida, Illinois, New Jersey, Ohio, Oklahoma, Rhode Island, Texas, or Washington, your state requires the use of a licensed/certified orthotist or prosthetist for furnishing orthotics or prosthetics. Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers in any one of these nine states planning to submit claims for Medicare payment for prosthetics and orthotics may enroll with the National Suppler Clearinghouse (NSC) and provide all required licenses and/or certifications to comply with Medicare requirements.
What You Need to Know Change Request (CR) 3959 puts new edits in the DMERC claims processing system that will look for specialty codes 51, 52, 53, 55, 56, 57, 65, 67, and all physician specialty codes listedin the Medicare Claims Processing Manual, Chapter 26, Section 10.8.2, in order to ensure that only those who specify P&O on their enrollment application forms (Form CMS-855S) are reimbursed for P&O supplies.
(Note: A copy of the state license for these specialty codes should also be on file at the NSC.)
What You Need to Do Make certain that your billing staffs provide your specialty codes, required licenses, and/or certifications to the NSC.
Background At this time, DMERCs process claims from enrolled and approved DMEPOS suppliers without noting the specialty identified and services to be provided on the enrollment application form (Form CMS-855S). Because there is no national Medicare policy regarding who may bill and be paid for prosthetics and certain custom-fabricated orthotics, the NSC follows state requirements that are in place in the (currently) nine states that require the use of an orthotist or prosthetist for furnishing of orthotics or prosthetics.
New Specialty Code Edits The claims system used by the DMERCs will have new edits-effective for services supplied on or after the implementation date for this CR-that look for specialty codes to ensure t hat suppliers billing for prosthetics and/or orthotics are permitted to bill in accordance with the law in the applicable states. CMS regulations (see 42 CFR 424.57©) require that all DMEPOS suppliers wishing to bill Medicare meet all supplier standards. The standard in Section 424.57©(1) requires suppliers to operate their business and furnish Medicare-covered items in compliance with all applicable federal and state licensure and regulatory requirements.
The following specialties may be licensed or certified by the state when applicable, and they can bill for Medicare services when state law permits them to furnish prosthetic or orthotic items:
Specialty
Specialty Code Medical Supply Company with Orthotics Personnel 51 Medical Supply Company with Prosthetics Personnel
52 Medical Supply Company with Orthotics and Prosthetics
Personnel
53 Orthotics Personnel
55 Prosthetics Personnel
56 Orthotics Personnel, Prosthetics Personnel, and Pedorthists
57 Physical Therapist
65 Occupational Therapist
67 All physician specialty codes listed in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 26, §10.8.2.
If you are located in one of the nine states listed in this article, check with the NSC to make certain that the correct specialty code is on file. The NSC is responsible for maintaining a central data repository for information regarding suppliers.
To ensure that your correct specialty code is on file and/or you need to update your file with thecorrect code, you must submit to the NSC a “Change of Information” on the CMS-855S form. The NSC will transmit this information to your DMERC.
Implementation
The implementation date for this instruction is October 3, 2005.
Additional Information
You can find more information about payment to suppliers qualified to bill Medicare for prosthetics and certain custom-fabricated orthotics, including the complete list of
Healthcare Common Procedure Coding System (HCPCS) codes for customized orthotics and prosthetics affected by the edit by going to www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the Centers for Medicare & Medicaid Services (CMS) Web site. From that Web page look for CR 3959 in the CR NUM
column on the right, and click on the file for that CR. A list of the prosthetic and orthotic codes affected by this edit is attached to CR 3959.
The following is contact information for the NSC:
Toll Free Number: 866-238-9652
Web site: www.PalmettoGBA.com. Click on “Other Partners,” or click on “Providers,” then National
Supplier Clearinghouse.
Email: medicare.nsc@palmettogba.com
Mailing address:
National Supplier Clearinghouse P.O. Box 100142 Columbia, S.C. 29202-3142
Overnight Mailing Address:
National Supplier Clearinghouse 2300 Springdale Drive Bldg 1, AG-495 Camden, S.C. 29020