REIMBURSEMENT PAGE
This change was made to ensure that providers are not using L7367 to describe disposable lithium ion batteries in powered prostheses.
prior-authorization proposed rule is available at www.aopanet.org. While CMS has yet to release the final rule regarding its proposed expansion of its prior-authorization program, AOPA expects it to be published sometime during 2015, with implementation occurring within 60 days of the release of the final rule.
Proposed Prior Authorization
2015 will most likely bring developments related to CMS’s proposal to include certain lower-limb prosthetic HCPCS codes in a prior-authorization program. CMS announced its intent to subject these codes to prior authorization in a proposed rule that was published in the Federal Register on May 28, 2014. The proposed rule referenced the ongoing demonstration project relating to prior authorization of durable medical equipment power mobility equipment (power wheelchairs) and indicated that CMS intended to expand its prior-authorization authority by implementing a prior-authorization process for durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization or a high improper payment rate as established by the Office of the Inspector General or error rates reported by the Comprehensive Error Rate Testing contractors and that have an average purchase fee of $1,000 or greater or an average rental fee schedule of $100 or greater per month. In the proposed rule, CMS included a “master list” of DMEPOS items that CMS believed are subject to prior authorization. This list contained 89 lower-limb prostheses codes. Inclusion of a code on the master list does not guarantee that it will be subject to prior authorization. CMS suggested that it would initially limit the number of items that require prior authorization to a subset of items chosen from the master list. While this initial subset was not indicated in the proposed rule, CMS stated that once the subsets of items are chosen, they would be published in the Federal Register and will include a 60-day comment period prior to implementation. AOPA and its members provided extensive comments to CMS regarding potential flaws in the proposed rule as well as specific provisions that 18
DECEMBER 2014 | O&P ALMANAC
Competitive Bidding of OTS Orthoses
2015 will most likely bring developments related to CMS’s proposal to include certain lower-limb prosthetic HCPCS codes in a prior authorization program. AOPA believes must be incorporated into the final rule before prior authorization can be considered palatable for the O&P community. These provisions included the following: • Claims that receive prior authorization must not be denied for nontechnical reasons when the actual claim is submitted. • The immediate cessation of all postpayment review and Recovery Audit Contractor audit activity for any prosthetic L codes subject to prior authorization. • Recognition of the prosthetist’s clinical notes as part of the patient’s medical record as they pertain to justification of medical necessity and claim payment. • Reduced processing time for prior-authorization requests and resubmissions. • A higher dollar threshold for prosthetic L codes subject to prior authorization. A copy of AOPA’s extensive comments to CMS regarding the
Another issue that is expected to be in play in 2015 is the potential for inclusion of OTS orthoses in the Medicare competitive bidding program. The creation of specific OTS orthotic codes as well as the establishment of 25 “split codes” in 2014 that describe either custom-fitted or OTS versions of the same device signaled CMS’s intent to include OTS orthoses in future competitive bidding programs. While the timeline for the existing competitive bidding programs may delay the inclusion of OTS orthoses in competitive bidding until late in 2015 or possibly into 2016, it is clear that the question is no longer if OTS orthoses will be competitively bid but rather when they will be competitively bid. It is important to review your business practices today and determine what specific impact this program may have on your business and what changes will be necessary to protect it. The year 2015 looks to be a very active 12 months for the O&P community. Depending on how you view it, it will be either a year of challenges or a year of opportunity. Joe McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@aopanet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:
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