Additional Payment Edits for DMEPOS Orthotics Suppliers

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The Centers for Medicare & Medicaid Services (CMS) issued CR 12282 to communicate the addition of Healthcare Common Procedure Coding System (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.

Suppliers may need to complete Form CMS-855S for change of information and submit applicable licenses or certifications to the National Supplier Clearinghouse (NSC).

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. Claims for items furnished by personnel who are not licensed/certified orthotists or prosthetists by the state in which they practice will be denied.

The following states require a licensed/certified orthotist or prosthetist to furnish orthotics or prosthetics: Alabama, Arkansas, Connecticut, Florida, Georgia, Idaho, Illinois, Iowa, Kentucky, Maryland, Minnesota, Mississippi, Nevada, New Jersey, North Dakota, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, and Washington.

In these 21 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.

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

Effective for dates of service on or after October 1, if a supplier is located in one of the applicable states and wishes to bill Medicare for the prosthetics and custom-fabricated orthotics, it must properly enroll with the NSC to ensure the correct specialty code(s) is on file.

To update an existing file with the correct specialty, submit a Change of Information on Form CMS-855S.