Background of Proposed Rule CMS-6012-P
- Establishment of Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom-Fabricated Orthotics
Three pieces of previously passed legislation modifying the Social Security Act of 1935 are the basis for the proposed rule affecting payment for custom-fabricated orthoses (c/f O) and prostheses (P) for Medicare beneficiaries.
The first was precipitated by a report by the Office of Inspector General issued in October 1997 exploring the extent of questionable billing of Medicare for orthotics, which concluded that 19% were medically unnecessary, 68% of unnecessary orthotics were provided by a DME company and 35% by orthotists. (You are correct: This adds up to more than 100%). They also concluded 68% of billed orthoses from SNFs were “questionable” and were typically provided by DME companies. They concluded there was a need to develop guidelines better defining orthoses; distinguish between custom-made and OTS; develop policies for the codes for which they prioritized upper-limb devices identified as being the most problematic; work with American Orthotist and Prosthetist Association to develop a table of devices that should not be used together; and consider stricter standards for identifying who was allowed to bill for orthotics (sic), such as requiring professional credentials for orthotic suppliers. 1
Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) which became part of Public Law 106-554, adopted in December 21, 2000.
- Amended §1834(h)(1)(F): “No payment will be made for c/f O or P unless furnished or fabricated by a qualified practitioner or supplier at a facility that meets criteria the Secretary of Health and Human Services determines appropriate.
- Qualified practitioner is a physician or other individual who is a qualified PT or OT; is licensed in orthotics or prosthetics; in the cases where the state provides such licensing, or in states where the state does not provides such licensing, is specifically trained and educated to provide or manage the provision of prosthetics and custom-designed or fabricated orthotics AND is certified by the ABC or the BOC; OR is credentialed and approved by a program that the Health and Human Services Secretary determines has the training and education standards that are necessary to provide such prosthetics and orthotics.
- Scheduled to go into effect one year after adoption. (December 21, 2000, in effect December 21, 2001)
A committee was established to determine how to enact the law, but the committee was unable to reach consensus by 2003.
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA)
- Added §1834(a)(20): requiring HHS Secretary to implement quality standards for suppliers of items and services including orthotics and prosthetics as a condition of obtaining a DMEPOS supplier number and being reimbursed by Medicare.
- Directed HHS Secretary to designate independent accreditation organizations to enforce the quality standards.
- Established procedures for designation of national accreditation organizations.
The Quality Standards were published in 2006 and 11 accreditation organizations were approved. Presently, nine of those organizations are still active; six are approved for credentialing c/f O and P.
Medicare Improvement for Patients and Providers Act of 2008 (MIPPA)
- Suppliers had to show evidence of accreditation by one of the accreditation organizations.
- HHS Secretary was given the right to exempt “eligible professionals” including qualified OTs, PTs and physicians as well as “Other Persons,” such as orthotists and prosthetists, from the quality standards and accreditation requirements unless the HHS Secretary determined the standards were specifically designed to be applied to the eligible providers and other persons.
- Eligible professionals were identified as ”MDs, PAs, nurse practitioners, certified nurse specialists, anesthetists, certified nurse midwives, clinical social workers, clinical psychologists, PTs, OTs or SLPs.
The exception has been in place for eight years. No new reports have been issued by OIG on Medicare orthoses billing and therefore, no data is available to measure the efficacy of the payment changes on fraudulent billing.
On January 11, 2017, HHS Secretary Sylvia Burwell and CMS’ Acting Director Andy Slavitt released the proposed rule, which was published in the Federal Register on January 12, 2017 with a 60-day comment period.
On January 24, 2017, the current administration issued an executive order directing all federal agencies to stop sending any new regulations to the Federal Register until otherwise directed. Any regulation sent to the Federal Register but not published was ordered to be withdrawn. This had no effect on the proposed rule, which had already been published.2
- Effective one year from implementation, all practitioners and suppliers billing Medicare for c/f O or P will be required to be accredited by the American Board for Orthotists and Prosthetists Certification (ABC).
- All facilities where any c/f O or P are fabricated must be accredited by ABC.
- All facilities where any c/f O or P are fabricated must have specific equipment.
(click here to view list)
CMS does not believe beneficiary access to care will be significantly affected and the benefit in improved quality of care outweighs any possible discontinuity of care. CMS states the goal is to ensure that the specialized needs of Medicare beneficiaries who require prosthetics and c/f orthotics are met.
- Department of Health and Human Services Office of Inspector General. Medicare Orthotics. October 1997: https://oig.hhs.gov/oei/reports/oei-02-95-00380.pdf (accessed online 1/29/17).
- Federal Register January 24, 2017, 82;14 :8346: https://www.gpo.gov/fdsys/pkg/FR-2017-01-24/pdf/2017-01766.pdf (accessed 1/25/17).
- List of affected orthotics and prosthetics: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/CMS-6012-P_HCPCS_Code_List.pdf (accessed 1/20/17).
- Federal Register January 12, 2017. 82;8:3678-3694: https://www.federalregister.gov/documents/2017/01/12/2017-00425/medicare-program-establishment-of-special-payment-provisions-and-requirements-for-qualified (accessed online 1/16/17).
Orthotics Certification Update (January 24, 2017)
ASHT is working with APTA and AOTA as well as HTCC to gather information in order to respond to the proposed rule which would require orthotics and prosthetics certification of all providers billing Medicare for orthoses.
The proposed rule would stop payment for custom fabricated orthotics to any provider lacking orthotist and prosthetist accreditation or certification. Questions and requests for more information should be directed to John Speigel at 410-786-1909.
Proposed Payment Changes for Orthotics and Prosthetics (January 19, 2017)
CMS published a new proposed rule that could severely limit the ability of hand therapists to be paid for custom-fabricated orthoses. Rule CMS-6012-P “Establishment of Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom Fabricated Orthotics,” published in the Federal Register January 12, 2017, removes exemptions to quality standards and orthotic certification for OTs and PTs, and would require licensure in orthosis fabrication by the state or the American Board for Certification in Orthotics and Prosthetics or the Board for Orthotist/Prosthetist Certification or a program “approved by the HHS Secretary.” Suppliers who do not meet the standard will not receive payment for custom-fabricated orthoses, and may face revocation of both their Medicare and DMEPOS eligibility. ASHT, in conjunction with HTCC, APTA’s Hand Academy and AOTA, are drafting comments on the proposed rule and will update members as more information is revealed.
Intervention Code Revaluation (November 9, 2016)
CMS announced in the 2017 Final Payment Rule, released November 2, 2016, that it would move forward with revaluing certain intervention codes. The AMA developed a valuation survey that is being randomly distributed by AOTA and APTA. The information obtained from this survey will be used to determine the code values. The O & P codes (97760-97762) are also being reviewed. APTA and AOTA obtained special permission from the AMA to target survey hand therapists in their associations. If you receive one of these surveys, it is extremely important that you fill it out and return it as soon as possible. Your responses will determine the value of these codes for 2018.
Medicare Final Payment Rule (November 4, 2016)
CMS released the Final Payment Rule on November 2, 2016. This 1,400-page document confirms that the new evaluation codes will begin January 1, 2017. Information on the therapy cap for 2017 and the value of the evaluation codes was also included in the rule. The Federal and State Regulations Committee is reviewing the document and will post pertinent information as soon as possible.
New Evaluation Codes and Descriptors for January 1, 2017 Released by CMS (July 11, 2016)
On July 8, CMS released proposed revisions to the Medicare Part B payment policies under the Physicians Fee Schedule. Included in these revisions were the new proposed evaluation codes scheduled to go into effect January 1, 2017. CMS has requested comments from specialty organizations on these rules and ASHT is working to identify concerns and address them in correspondence to CMS.
Please send your comments and concerns regarding the codes to ASHT@ASHT.org with the subject: New Evaluation Codes.
Assistants and L code Billing (May 31, 2016)
ASHT has recently confirmed that Medicare does not have restrictions on COTAs or PTAs billing L codes under the supervision of their respective PT or OT. Although Medicare does not have this restriction, individual state laws may be more restrictive. Providers should confirm that orthotic fabrication is within the scope of practice in their respective state practice acts.
Reimbursement News (August 28, 2015)
If your clinic had Medicare Advantage reimbursement cut due to sequestration, you may want to check out a new article in Modern Healthcare. Florida providers are suing Humana over reimbursement cuts to providers for services under their Medicare Advantage Plan.
Humana reduced reimbursement 2%, citing the cuts were part of the sequestration and were in response to CMS cutting reimbursement to Medicare Advantage carriers. They stated they were acting as “federal officers” on behalf of a federal agency (CMS). The providers contend the cuts violated their Humana contracts. The case was reviewed in U.S. District court in Miami where the judge ruled “Humana’s payments to providers are governed by its contracts with those providers and not federal laws or programs, and that CMS did not tell Medicare Advantage Plans how to handle the sequestration cuts.” Similar cases are being heard in other states and against other insurers, e.g. Pennsylvania vs. Highmark.