Payment Accuracy CMS Medicare & Medicaid Futureproof Claims Program Integrity

CMS Issues Additional Payment Edits for DMEPOS Suppliers

Steven A Greenspan JD LLM

CMS Adds Five (5) States Requiring Licensure & Enrollment with NSC  

The Centers for Medicare and Medicaid Services (CMS) issued Transmittal 11002, Change Request (CR) 12282 (r11002otn.pdf (cms.gov), on September 13, 2021, 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. These codes are in addition to those codes previously identified in CR 3959, CR 8390, and CR 8730. This change will apply to dates of service on or after October 1, 2021. 

While the stated purpose of the CR is to communicate the addition of Healthcare Common Procedure Coding System (HCPCS) codes, which require the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics (OR01 Orthoses: Custom Fabricated and OR02 Orthoses: Prefabricated (Custom Fitted)), the main focus of the CR is to advice Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers that if they are located in one of the applicable states and wish to bill Medicare for the prosthetics and custom fabricated orthotics attached to this CR, it must properly enroll with the National Supplier Clearinghouse (NSC) to ensure the correct specialty code(s) is on file. The effective date for the new or revised specialty code for prosthetics and orthotic claims will be the date the NSC issues the specialty code. According to CMS, the new or revised specialty code will not be applied retroactively. 

A copy of any state licenses should be sent to the NSC if the supplier is in one of the states requiring a license. If a supplier should need to update its’ file with the correct specialty, the supplier must submit a “Change of Information” on Form CMS-855S to the NSC along with all applicable licenses or certifications. 

Compliance with Requirements 

In order to remain compliant with all applicable federal and state licensure and regulatory requirements, CMS regulations require DMEPOS suppliers to operate their business and furnish Medicare-covered items only by personnel who are licensed/certified orthotists or prosthetists by the state in which they practice. 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. The five (5) bolded states were added to the list of states requiring a licensed/certified orthotist or prosthetist to furnish orthotics or prosthetics effective October 1, 2021. Rhode Island is no longer included in the list of states requiring licensure. 

Medicare payment may only be made for prosthetics and certain custom-fabricated orthotics when furnished by physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel and prosthetics personnel. These specialties can only bill for Medicare services when State law permits such entity to furnish an item of prosthetic or orthotic.  All Physician Specialty Codes have been hard-wired into the ViPS Medicare System (VMS). 

  • Medical Supply Company with Orthotics Personnel – Specialty Code51; 
  • Medical Supply Company with Prosthetics Personnel – Specialty Code52; 
  • Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code53; 
  • Orthotics Personnel – Specialty Code55; 
  • Prosthetics Personnel – Specialty Code56; 
  • Orthotics Personnel, Prosthetics Personnel, and Pedorthists– Specialty Code 57;  
  • Physical Therapist – Specialty Code65; 
  • Occupational Therapist – Specialty Code67; 
  • Pedorthic Personnel - Specialty Code B2;  
  • Medical Supply Company with Pedorthic Personnel - Specialty Code B3 
  • Ocularist – Specialty Code B5

Please remember that if you are furnishing orthotics or prosthetics in any of the 21 designated states, make sure to utilize only licensed or certified personnel to furnish these items, otherwise your claims may be denied.  Claims may also be denied if you use licensed or certified personnel to furnish these items but fail to provide a copy of their license/certificate or fail to enroll the proper specialty code with the NSC. Additionally, if you do furnish any of these items by unlicensed or uncertified personnel in a state that requires licensure/certification, and you are paid by the DME MAC, you have an obligation to repay those funds or you may be subject to enforcement activity, including but not limited to civil money penalties, false claims actions, and exclusion from government programs.  

Compliance with applicable state and federal licensure and regulatory requirements is the key to Ensure Payment Accuracy and FutureProof Your Claims.