Announcements/Updates

Opioid Crisis Response Act of 2018 (H.R. 6) - Bill Signing
(October 26, 2018)

This week, President Donald Trump signed into law the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (H.R. 6). The new law represents the culmination of an intense year-long legislative effort to stem the opioid crisis.

During the debate, ASHT emphasized with lawmakers the importance of helping people find non-opioid alternatives to managing their pain, including hand therapy. We are pleased that the final agreement adopted a number of key policies that could benefit the hand therapy profession and the clients you serve, including provisions that would:

Direct CMS to issue guidance to states for treating and managing Medicaid beneficiaries’ pain through non-opioid pain treatment and management options, including coverage and reimbursement recommendations.

Require the Secretary of HHS to submit a report on ways to improve reimbursement and coverage for multi-disciplinary, evidence-based non-opioid chronic pain management.

Require the Secretary of HHS to develop guidance and a toolkit on pain management and opioid use disorder prevention for hospitals receiving payment under Part A of the Medicare program.

Update the scope of the Interagency Pain Research Coordinating Committee to identify, among other things, advances in pain care research supported or conducted by the federal government, including information on best practices for the utilization of non-pharmacologic treatments.

Incentivize the treatment of individuals with substance use disorders by establishing a loan repayment program for eligible health care professionals working in shortage areas or counties that have been hardest hit by drug overdoses.

The hard work, however, has just begun. The agencies will soon initiate the rulemaking process, develop parameters for incentivizing non-pharmacological treatments, and examine critical reimbursement incentives. With that in mind, ASHT is preparing to engage CMS and other key agencies as they seek input in the coming months. We will continue to keep you updated on any new developments.
 


2019 Medicare Physician Fee Schedule
(October 2018)

On September 10, 2018, ASHT submitted a letter to the Centers for Medicare and Medicaid Services (CMS) in response to the proposed 2018 Medicare Physician Fee Schedule and related policies included in the proposed rule. 

View the full letter here


Opioid Crisis Response Act of 2018 (H.R. 6)
(September 2018)

The Senate is poised to consider comprehensive legislation aimed at addressing the nation’s opioid crisis. Please contact your Senator today.

The Opioid Crisis Response Act of 2018 (H.R. 6) represents a critical step in Congress’s year-long effort to advance meaningful policies to address substance use disorders. The bill seeks to address the opioid crisis by providing key tools and resources aimed at better identifying and treating individuals with substance use disorders. H.R. 6 recognizes the importance of promoting non-opioid alternatives to pain management, including the contributions of rehabilitation and therapy.

The bill includes a number of relevant policies for Hand Therapists including provisions that would:

  • Direct the Department of Health and Human Services (HHS) to study ways to improve access to non-opioid pain management treatments, including therapy and rehabilitation.
  • Seek stakeholder input to develop guidance on pain management and opioid use disorder under part A of the Medicare program
  • Update pain care programs to include alternatives to opioid pain treatment and by promoting non-addictive and non-opioid pain treatments, and non-pharmacologic treatment.
  • Require that the annual Medicare & You handbook for Medicare beneficiaries to educate on non-opioid alternatives for pain management.
  • Direct CMS to issue guidance to states for treating and managing pain through non-opioid treatment under Medicaid.

Hand therapists have a crucial role to play in addressing the opioid epidemic. Whether it is following an upper extremity injury, surgery, or helping manage a chronic condition, hand therapists provide safe, quality, and effective pain care management for their clients.

Please continue to help us advocate for the hand therapy profession by sharing your voice and experience with your Senators. Together we can work to shape policy and ensure rehabilitation remains an important part of the comprehensive solution to address the opioid epidemic.

Please call your Senators to urge them to pass comprehensive opioid legislation, and tell them to make therapy and rehabilitation part of the response to our nation’s substance use crisis.


Congress Faces Packed September Work Schedule
Opioid Legislation and Looming Funding Battle Await
(August 2018)

Following House passage of Support for Patients and Communities Act (H.R. 6) in June, the Senate has worked to craft a legislative package of its own with negotiations hitting a key milestone last week. Republican leadership announced at an August 28 press conference that GOP Senators have reached consensus on underlying opioid legislation and hope to bring a bill to the floor shortly upon their return this month. Senate Democrats, led in negotiations by Senator Patty Murray (D-WA), continue to study the proposal and the Senate ultimately will need to reconcile key provisions of its bill with differences in H.R. 6. Yet the two proposals share some elements in common.

Like H.R. 6, the Senate bill would encourage the use of non-opioid alternatives to pain management and would emphasize multi-modal approaches across settings and reimbursement structures. The bill would also seek to expand access to substance use disorder treatment, support research, and prevent drug diversion.

Hand therapists have a crucial role to play in addressing the opioid epidemic. Whether rehabilitating an upper extremity injury, assisting with recovery post-surgery, or helping manage a chronic condition, hand therapists provide safe, quality, and effective pain care management for their clients.

Please call your Senators to urge them to pass comprehensive opioid legislation, and tell them to make therapy and rehabilitation part of the response to our nation’s substance use crisis.

While the House recessed last month, the Senate also considered the Fiscal Year 2019 Labor, Health and Human Services, Education, and Related Agencies (LHHS-ED) appropriations bill. This is Congress’ largest funding bill and has jurisdiction over virtually all federal health care programs. Passage of the LHHS-ED bill is noteworthy, as in recent years, it has served as a magnet for controversial health policy amendments.

The Senate passed this critical spending bill in an 85-7 vote with overwhelming bipartisan support. As passed, the bill would provide significant new investments in our nation’s current health care priorities and represents a departure from President Trump’s proposal to cut $12.5 billion in spending. These new investments include: $5 billion over Fiscal Year 2017 for the National Institutes of Health, $3 billion over Fiscal Year 2017 to combat the opioid crisis, and $2.3 billion over Fiscal Year 2017 to increase college affordability. While the House did not call up its own bill for a floor vote, Representatives on September 4 agreed to combine the LHHS-ED and Defense spending bills and negotiate a final package with the Senate. Some House conservatives objected to withholding a separate vote on LHHS-ED but Republicans generally are optimistic about the bill’s likelihood of passing.

Two upcoming dates add pressure to Congress to reach an agreement on Fiscal Year 2019 spending as well as on opioids legislation: the expiration of current government funding on September 30 and the 2018 midterm elections on November 6. ASHT will continue to keep you updated on these and other key issues as Congress acts in these last weeks of the year.


2019 Medicare Physician Fee Schedule
(July 2018)

The 2019 Medicare Physician Fee Schedule proposed rule is out and will, undoubtedly, impact hand therapy services under Medicare Part B. ASHT is examining these proposals closely with your practice in mind. The following provides an overview of important changes on the horizon for hand therapy:

Functional Limitation Reporting (FLR)

Among the most important and welcoming changes for hand therapists is the proposal by CMS to eliminate FLR. Since 2013, OTs and PTs have been required to assign G-codes to their claims for the purposes of fulfilling CMS’ pursuit of value-based payment. ASHT is pleased that CMS has acknowledged the shortcoming of this data collection and the unnecessary burdens and complexities associated with the documentation mandate.

Quality Payment Program (QPP)

CMS is proposing that OTs and PTs providing services under Medicare Part B join the QPP by participating in either the Merit-based Incentive Payment Program (MIPS) or an Alternative Payment Model (APM) beginning in 2019.

The QPP consists of two participation pathways – MIPS, which measures performance in four categories to determine an adjustment to Medicare payment, and APMs, in which clinicians may earn an incentive payment as well as an exemption from MIPS reporting requirements.

Under MIPS, data is collected in four key areas: quality, resource use, clinical practice improvement activities, and interoperability of electronic health records. These categories are combined to determine your Composite Performance Score. The total score ultimately determines whether providers are eligible for a payment bonus or payment reduction.

While OTs and PTs have not been eligible participants to date, therapists have been allowed to voluntarily report data as a means of gathering feedback in anticipation of eventually being required to meet the program’s reporting requirements.

Low Volume Exemption: MIPS includes an exemption for smaller private practices through a Low Volume Threshold policy. The policy states that if any one (1) of the following applies, the practitioner is not required to report under MIPS: the practitioner has Medicare-allowed charges of less than or equal to $90,000; provides covered services to 200 or fewer beneficiaries; or provides 200 or fewer services to beneficiaries.

Therapy Cap Repeal Implementation

The passage of the Bipartisan Budget Act of 2018 ended the long-fought battle over Medicare’s Part B therapy cap. The repeal of the cap also included a number of additional provisions that are addressed in the recently released MPFS proposed rule, including requirements to continue the use of the KX modifier for claims exceeding $2,010 for OT and for PT and speech-language pathology (SLP) services combined. While affixing the KX modifier is still required, all claims above that threshold will not be subject to review.

Perhaps the most surprising provision in the Bipartisan Budget Act of 2018 was language aimed at OTAs and PTAs. The MPFS addresses this provision by proposing the use of modifiers when PTAs or OTAs are providing outpatient services. Ultimately, the modifiers will be utilized to implement a reduction in reimbursement for OTAs and PTAs. The legislation calls for such services to be paid at 85% of the fee schedule beginning in 2022. Voluntary reporting could begin as soon as 2019, according to the proposed rule. ASHT has significant concerns with this proposal and will be exploring legislative and regulatory remedies to reverse this policy.


​U.S. House of Representatives Passes Opioid Legislation
(June 29, 2018)

Last week, the House of Representatives passed H.R. 6: Support for Patients and Communities Act, a critical step toward passing comprehensive opioid legislation in the 115th Congress.

The bill seeks to address the opioid crisis by providing key tools and resources aimed at better identifying and treating individuals with substance use disorders. Importantly, H.R. 6 recognizes the importance of promoting non-opioid alternatives to pain management, including the contributions of rehabilitation and therapy.

Among many key provisions, the SUPPORT for Patients and Communities Act (H.R. 6) would:

  • Direct the Department of Health and Human Services (HHS) to study ways to improve access to non-opioid pain management treatments, including therapy and rehabilitation.
  • Seek stakeholder input to develop guidance on pain management and opioid use disorder under part A of the Medicare program.
  • Convene technical expert panels aimed at reducing surgical and post-surgical opioid use.

Hand therapists have a crucial role to play in addressing the opioid epidemic. Whether it is following an upper extremity injury, surgery, or helping manage a chronic condition, hand therapists provide safe, quality, and effective pain care management for their clients.

As attention now turns to the Senate to act, please continue to help us advocate for the hand therapy profession by sharing your voice and experience with your Members of Congress. Together we can work to shape policy and ensure rehabilitation remains an important part of the comprehensive solution to address the opioid epidemic.

Please contact your Senators to urge them to pass comprehensive opioid legislation, and tell them to make therapy and rehabilitation part of the response to our nation’s substance use crisis.

Be heard: Visit the ASHT Legislative Action Center


Opioid crisis takes center stage as Congress prepares for upcoming Memorial Day recess
(June 1, 2018)

Congress continues to take aim at the opioid epidemic with hopes of passing a comprehensive legislative package before lawmakers leave for August recess. Across the political spectrum, members of Congress recognize the importance of alternative treatments for pain. As hand therapists, your daily efforts to minimize client pain and maximize function offers a true alternative to opioids, and Congress agrees!

Last week, the House Ways and Means Committee approved the Medicare and Opioid Safe Treatment (MOST) Act (H.R. 5776) with overwhelming bipartisan support. Among other things, H.R.5776 would require the Secretary of Health and Human Services to examine avenues to improve access to services such as cognitive behavioral interventions, physical therapy, occupational therapy and physical medicine.

The House Energy and Commerce Committee was also busy at work last week, approving 57 bills over a marathon two-day markup. Included among the bills was the Medicare Opioid Safety Education Act (H.R.5685), which seeks to bolster educational resources available to Medicare and Medicaid beneficiaries on pain management and alternative pain management treatments, like therapy. Bills like H.R.5776 and H.R.5685 represent prime opportunities for hand therapists to highlight the benefits of rehabilitation. We anticipate that the House could vote on a combined package of opioid bills as early as June 11.

Meanwhile in the Senate, the HELP Committee considered and approved S.2680: The Opioid Crisis Response Act of 2018, while the Senate Finance Committee followed suit with a legislative package consisting of 22 bipartisan policy proposals. The Senate hopes to bring the complement of bills to the Senate floor in the coming month for full consideration.

Members of Congress are currently back home this week for Memorial Day “recess,” and it’s a perfect time to let them know what you do, how you help your clients and how therapy and rehabilitation are vital solutions to the opioid epidemic. Your voice and experience are a critical piece of the puzzle.  In fact, we've even created a member survey so we can capture your experiences and better educate lawmakers.  Please take time to tell your story.  As you have conversations with members of Congress back home, be sure to let ASHT know so we can reinforce your message when members return to Congress in June.


ASHT Pain Management Survey

As Congress continues to consider legislation to address the opioid epidemic, ASHT wants to hear from you!​

We want your voice and experience to resonate in this broader debate as ASHT continues to monitor these developments and work to shape policy to address the opioid epidemic. Knowing how you have helped clients manage chronic and acute pain through therapy and rehabilitation is a critical piece of the solution to this nationwide crisis. 

Thank you for taking the time to complete this brief survey examining the role hand therapists play in battling the opioid epidemic. The information gathered may be used and presented to physicians, insurers and legislators by ASHT.


Congress Considers Legislation to Address the Opioid Epidemic - Hand Therapy Part of the Solution 
(May 1, 2018)

Over the past few months, we’ve seen a flurry of debate on Capitol Hill around the opioid epidemic. This week marked the first significant steps taken this year toward advancing comprehensive legislation on this critical topic.

On April 24, the Senate Committee on Health, Education, Labor and Pensions (HELP) marked up S.2680: The Opioid Crisis Response Act of 2018. This bipartisan bill was a combination of 40 different policy proposals, cobbled together over seven bipartisan hearings on how to best address the opioid crisis. The Opioid Crisis Response Act of 2018 aims to accomplish many items, including:

  • Require the Secretary of HHS to provide technical assistance related to the use of alternatives to opioids, including for common painful conditions and certain patient populations, such as geriatric patients, pregnant women and children.
  • ​Spur development and research on of non-addictive painkillers, and other strategies to prevent, treat and manage pain and substance use disorders through additional flexibility for the NIH.
  • Support the healthcare workforce by providing resources for pain care providers to assess, diagnose, prevent, treat and manage acute or chronic pain, as well as for the detection of early warning signs of opioid use disorders.

The Senate HELP Committee advanced S.2680 unanimously by a vote of 23-0. Chairman Lamar Alexander (R-KY) expressed his hopes that the full Senate will move the opioid legislation by this summer.

On April 30, the House Energy and Commerce Health Subcommittee concluded their opioid markup, advancing 56 opioid related bills to the full Energy and Commerce Committee. This full docket, comprised of introduced bills and draft legislation, offered a broad range of solutions to the crisis, across the areas of public health, behavioral health and Medicare and Medicaid reimbursement. According to Chairman Burgess (R-TX), the full committee markup is likely to take place in mid-May.

Among the drafts to advance was the Adding Resources on Non-Opioid Alternatives to the Medicare Handbook, which would direct CMS to compile educational resources for beneficiaries regarding opioid use, pain management and alternative pain management treatments. The legislation goes on to instruct CMS to include these resources in the “Medicare and You” handbook. Legislation like this gives ASHT the opportunity to emphasize the benefits of therapy as well as the work you do as therapists to minimize client pain and maximizing function.

As Congress continues to consider legislation like this to address the opioid epidemic, we want to hear from you! Knowing how you have helped clients manage chronic and acute pain through therapy and rehabilitation is a critical piece of the solution to this nationwide crisis.

We want your voice and experience to resonate in this broader debate as ASHT continues to monitor these developments and work to shape policy to address the opioid epidemic. Share your personal experiences, stories, and background to asht@asht.org, so we can tell Congress that Hand Therapy is part of the solution.  


Hand Therapy Practice and the Opioid Epidemic (April 6, 2018)

Hand therapists have a crucial role to play in addressing the opioid epidemic. Whether it is following an upper extremity injury, surgery, or helping manage a chronic condition, hand therapists provide safe, quality, and effective pain care management for their clients.

In recent months, Washington has turned its attention to the opioid epidemic, providing nearly $4 billion in new spending in the recent funding bill and debating dozens of bills to address the multi-faceted crisis. When Congress returns from recess next week, lawmakers will seek to continue the momentum.

On April 11th, the House Energy and Commerce Committee will hold a legislative hearing to examine a new slate of bills aimed at curbing opioid use by, among other things, addressing Medicare and Medicaid coverage barriers, tracking opioid prescribing patterns, requiring drug companies to alter packaging, and allowing providers to write smaller prescriptions. In addition, the Centers for Disease Control and Prevention and now Blue Cross Blue Shield are actively advocating for a new standard that emphasizes non-opioid alternatives as the first line of treatment for pain management over opioid prescribing.

As the debate unfolds over the coming months, ASHT will continue to educate lawmakers about the important role hand therapists play in safe, effective pain management. ASHT will also be emphasizing the importance of non-opioid alternatives to pain management and working to improve and support policies that embrace the benefits of therapy and rehabilitation.

Stay tuned to ASHT's Legislative Action Center for updates on this issue.


Victory! Repeal Becomes Law (February 9, 2018)

This morning, February 9th, President Trump signed the latest stopgap funding bill into law, which included the Permanent Repeal of the Medicare Therapy Cap!

Today marks a huge victory for the profession that was twenty years in the making.  As a member of the American Society of Hand Therapists, we wanted to thank you, sincerely, for your steadfast commitment to addressing this critical issue. You have lent your voice to this cause many times, and today, your emails and phone call were finally heard. Today, we can finally say, “The Medicare Therapy Cap is repealed!”

As we look to the future, we recognize that this victory is one part of a larger journey to ensure people have access to therapy services and ultimately a chance at functioning fully.  We must now look to continue seeking improvements through the rulemaking and implementation phases of this permanent repeal.  Your voice will be vital to this process as we find the best path forward for the profession.

Thank you for all of your support and congratulations on a job well done!

For more information on the new law, visit our Legislative Action Center


Medicare Therapy Cap (February 7, 2018)

Swift action in the House of Representatives this week has brought full and permanent repeal of Medicare's outpatient therapy cap one giant step closer to reality. Since 1997, ASHT and its allies in the therapy community have fought long and hard to repeal this harmful and arbitrary cap on Medicare beneficiary care. Our chance for victory is now!

On Monday evening, House negotiators unveiled a spending package aimed at avoiding another government shutdown and quickly readied it for consideration. The measure would extend government funding at current levels through March 23rd and address a slate of expired Medicare 'extender' policies, including a permanent solution to Medicare's outpatient therapy cap. Following debate yesterday afternoon, the House passed the bill last night by a margin of 245-182.

In addition to immediately repealing the therapy cap, the language codifies the targeted review mechanism as well as the use of the KX modifier after a threshold of $3,000. In exchange for these changes and the corresponding costs associated with repealing the cap, negotiators included an offset that would reduce payment for therapy assistant (OTA and PTA) services beginning in 2022 to 85% of what is currently reimbursed. In the remainng time before the Senate considers its version, ASHT will work with its allies in the therapy community to advocate for an alternative offset. 

With the Senate poised to make changes, it's critical your Senators hear from you today. We need your help to ensure this giant step forward in the Houe is indeed a path to victory. Please contact your senators today and urge them to permanently repeal the therapy cap. 


Medicare Access to Rehabilitation Services Act (January 24, 2018)

After a weekend of wrangling, the House and Senate reconvened this past Monday and agreed to end its shutdown stalemate.  Ultimately, Congress approved an amended continuing resolution (CR) that reopened the government and extended funding through Feb. 8th. The agreement also reauthorized and funded the popular Children's Health Insurance Program (CHIP) for six-years and delayed a number of ACA-related tax provisions imposed on medical devices, high-cost health plans, and health insurers.

Despite progress, Congress faces a lengthy to-do list in the coming weeks, including finding a long-term solution on FY2018 spending levels, reaching compromises on immigration, passing health insurance market stabilization measures, and, importantly, addressing expired Medicare extenders policies, like the outpatient therapy cap.

With some of our nation’s frailest seniors projected to hit the cap later this month and the Centers for Medicare and Medicaid Services (CMS) currently holding claims for physical, speech, and occupational therapy, we are quickly reaching an untenable situation. It’s critical that our voice resonate above the noise and negotiations of Washington, especially in the coming days. A bipartisan solution to permanently address the therapy cap exists, and ASHT strongly urges you to reach out to your Members of Congress and call on them to support a permanent solution today!


CMS Proposed Orthotics and Prosthetics Rule Update

CMS has officially withdrawn the proposed orthotics and prosthetics rule (CMS 6012-P) published last January, which would require therapists to be certified in orthotics in order to receive payment for custom-fabricated orthotics for Medicare beneficiaries. Congratulations to all of our members who contributed comments in support of our profession! This victory was only possible because of the effort of every single person who chose to be involved.

For the CMS announcement follow this link: https://www.federalregister.gov/documents/2017/10/04/2017-21425/medicare-program-establishment-of-special-payment-provisions-and-requirements-for-qualified


Medicare Card Number Changes (July 17, 2017)

In an effort to protect Medicare and their beneficiaries from fraud and identity theft, and to protect program and personal information, CMS will be removing Social Security numbers from Medicare cards. Social Security-based Health Insurance Claim Numbers (HICN) will be replaced by a unique, randomly assigned Medicare Beneficiary Identifier (MBI) number.

CMS will begin mailing out replacement cards in April 2018, and the replacement process should be completed by April 2019.

CMS is developing a secure tool for providers to look up MBI numbers at point of service to facilitate this changeover.

Your systems need to be ready to accept the new MBI numbers by April 2018; however, there will be a 21-month transition period during which you can bill patient services using either a HICN or MBI number.

More Information


Another Update on Misvalued OT Evaluation Codes (April 14, 2017)

CMS has issued Change Request 9977, which states MACs are not responsible for searching through files to identify misvalued claims, but will adjust those claims brought to their attention retroactive to January 1, 2017. Occupational therapists should contact their individual MACs to determine how to resubmit the underpaid evaluation claims. Learn more


CMS Miscalculated OT Evaluation Code Rates (April 7, 2017)

AOTA discovered that CMS lowered the reimbursement rate on the new tiered occupational therapy evaluation codes due to an error in the amount used for the practice expense portion of the code in some MAC regions. AOTA met with CMS, who has corrected the error in its April Quarterly Update Transmittal and has communicated the correction to the Part B Medicare administrative contractors. The corrected rates should be posted soon and are retroactive to January 1, 2017.

No action is required on the part of providers; however, it is a good idea to keep checking the fee schedule to make sure the correction is put in place. Affected MAC regions should see an increase and receive the retroactive payments in the next months.


Background of Proposed Rule CMS-6012-P (February 6, 2017)

Background: 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

H.R.5661:

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

Rule Summary

  • 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.

  1. 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).
  2. 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).
  3. 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).
  4. 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).

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.