“Qualified Provider” DMERC Transmittal

The Centers for Medicare and Medicaid Services (“CMS”) recently announced new rules concerning “Payment to Providers/Suppliers Qualified to Bill Medicare for Prosthetics and Certain Custom-Fabricated Orthotics”. This transmittal, known as “Transmittal 329,” which will be effective on July 1, 2005, instructs Durable Medical Equipment Regional Carriers (“DMERCs”) to deny claims for prosthetics and certain custom-fabricated orthotics unless provided by a “qualified practitioner.” The transmittal also defines which individual codes they have included in the category of “Prosthetics and Certain Custom-Fabricated Orthotics”. Though it does not define specifically what constitutes a qualified practitioner, it does require that O&P practitioners be “certified,” whether billing independently or through a “medical supply company with a certified orthotist/prosthetist.”

BACKGROUND

Transmittal 329 is the latest effort by CMS to implement Section 423 of the Benefits Improvement and Protection Act of 2000 (“BIPA”). BIPA Section 423 requires CMS to define the term “qualified provider” in the context of orthotic and prosthetic services reimbursable by Medicare. As a result, CMS engaged members from the O&P community along with physical and occupational therapists to enter into a “Negotiated Rulemaking” process that would settle the issue of qualified provider as required under BIPA in addition to a large number of other issues that arose from the BIPA statute. The Negotiated Rulemaking process, however, failed to settle on a definition and parties did not reach consensus on significant issues. The Medicare Modernization Act of 2003 (“MMA”), Section 302(a), also requires CMS to define qualified practitioner, though not in as unequivocal a manner as BIPA.

Transmittal 329 specifies that unless a supplier has self-identified under one of the following categories during supplier enrollment and/or reenrollment, claims for certain O&P services will be denied:

  • Medical Supply Company with Certified Orthotist – Specialty code 51
  • Medical Supply Company with Certified Prosthetist – Specialty code 52
  • Medical Supply Company with Certified Orthotic and Prosthetist – Specialty code 53
  • Certified Orthotist – Specialty code 55
  • Certified Prosthetist – Specialty code 56
  • Certified Orthotist and Prosthetist – Specialty code 57

Aside from these categories and accompanying specialty codes, the transmittal does not define “qualified practitioner” in any explicit manner or by referencing BOC or ABC certification. Practitioners wishing to bill for prosthetics and/or custom-fabricated orthotics must re-enroll as Medicare suppliers before July 1, 2005, if their existing NSC applications did not designate their O&P certification.

ANALYSIS

Currently, DMERCs process and pay claims for prosthetics and custom orthotics without regard to the specialty that a supplier self-reports on the supplier number application form. On July 1, 2005, such O&P claims submitted by practitioners not specifying one of the above-mentioned specialties will be denied. In this respect, the key disagreement that arose in the Negotiated Rulemaking Committee between the O&P field and the therapy organizations has been largely resolved in the O&P field’s favor. CMS has essentially recognized the validity of the O&P community’s argument that ABC or BOC certification should be required in order to bill Medicare for O&P services, other than the portion of orthotics that is considered “off-the-shelf”. In addition, although additional analysis is required, the list of O&P codes that will require certification appears to be relatively expansive, which again cuts in favor of the O&P field.

The link to the announcement with the list of covered codes is:http://www.cms.hhs.gov/manuals/pm_trans/R329CP.pdf

November 18, 2004

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