Legislation & Regulation
HCPCS Codes Considered to be Off-The-Shelf (OTS) Orthotics
March 2012
On February 9, 2012, the Centers for Medicare & Medicaid Services (CMS) identified specific Healthcare Common Procedure Coding System (HCPCS) codes considered to be Off-The-Shelf (OTS) orthotics. Proposed list OTS is defined as an orthotic that requires minimal self-adjustment for appropriate use and does not require expertise in trimming, bending, molding, assembling or customizing to fit to the individual.
While the distinction between an orthotic and an OTS may not seem significant, the proposal would have significant impact on reimbursement. At some point, these items will go out for competitive bidding to set the fee schedule. Because OTs and PTs are exempt from competitive bidding, they would have no input on how the fees are set.
AOTA and APTA reached out to ASHT for assistance in formulating a response to CMS. After much deliberation between the three organizations, ASHT took the lead in preparing a position letter. It was ultimately decided that all three organizations would send a variation of this letter. ASHT’s Legislative Committee will continue to monitor this issue.
Cuts to Physicians Fee Schedule / Exceptions to Therapy Cap
UPDATE February 27, 2012
President Obama signed the Middle Class Tax Relief and Job Creation Act of 2012 (HR 3630) February 22. This bill prevents the mandated 27.4% cut to the physicians fee schedule and allows exception to the therapy cap of $1,880 combined SLP and PT and $1,880 for OT per fiscal year.
Provisions of the bill impacting hand therapists include:
- Modifier Use: Claims exceeding the $1,880 cap must include the KX modifier.
- Medical Review: Therapy claims exceeding $3,700 per year will trigger mandatory medical review. (This is per discipline, so $3,700 combined speech/PT and $3,700 OT.)
- NPI: All claims must contain the ordering physician’s NPI or the NPI of the physician who reviews and certifies the plan of care beginning October 1, 2012.
- Temporary Application of the Therapy Cap to Outpatient Hospital Settings: The therapy cap (with exceptions) will temporarily be applied to hospital outpatient departments beginning no later than October 1, 2012. This provision will sunset at the end of 2012 unless Congress extends it into 2013.
- MedPAC: Not later than June 15, 2013, MedPAC shall submit to the House Energy and Commerce Committee, House Ways and Means Committee and the Senate Finance Committee a report on how to improve the outpatient therapy benefit. The report will include recommendations on how to reform the payment system so the benefit is better designed to reflect individual acuity, condition and therapy needs of the patient. The report will examine private sector initiatives relating to outpatient therapy benefits.
- Data Collection: Beginning January 1, 2013, the Secretary shall implement a claims based data collection strategy designed to assist in reforming the Medicare payment system for outpatient therapy. The system will be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes. In proposing and implementing such a strategy, the Secretary will consult with relevant stakeholders.
- GAO Report on Manual Medical Review: Not later than May 1, 2013, the Comptroller General shall issue a report to the House Committee on Energy and Commerce, the House Ways and Means Committee and the Senate Finance Committee on the implementation of the manual medical review process. The report shall include data on the number of individuals and claims subject to the process, the number of reviews conducted and the outcome of the reviews.
