Medicare Opens Up O&P Coding Determination

BALTIMORE–Medicare posted more than 45 preliminary decisions
answering requests for a host of targeted orthotics and prosthetics
HCPCS codes on Wednesday. The agency also set a public meeting
covering all of the requests for early next month.

“This is the first time we’ve had public involvement in the
process,” said Joe McTernan, assistant director of reimbursement
services for the American Orthotics and Prosthetics Association.
“This represents a much more open process. I was surprised; this
wasn’t something you’d see in the past.”

O&P suppliers have faced a coding conundrum strikingly
similar to problems in the mobility sector: the L codes for these
products haven’t reflected the latest technologies, leading–at
least in part–to increased fraud and abuse from some
“stock-and-bill providers that have used existing coding to bill
beyond what’s appropriate,” said Pat Schelf, vice president of
marketing and general manager of Ortho Rehab, a division of Otto
Bock, Minneapolis.

So over the past several years, CMS has tweaked the codes to
match available technology, starting with back bracing products in
2003. “The existing [new] codes have more anatomically-based
descriptors,” McTernan explained.

CMS announced plans to open up its coding application process
for all DMEPOS following instructions from the agency’s Council on
Technology and Innovation, created by the Medicare Modernization
Act, and recommendations from various industry groups. Those groups
include the Coalitions of Wound Care, Respiratory Care and Seating
and Positioning Manufacturers. Marcia Nusgart, the coalitions’
executive director, said she had met with government officials over
the coding issue for four years before CMS announced it would
reform its HCPCS assignment process last November. The agency
expects to implement further changes, including an appeals process,
for the 2007 coding cycle.

“This is a giant step,” Nusgart said last year in response to
the announcement. The changes are “going to make the process a lot
more understandable as well as transparent. We are very pleased
that CMS responded to many of our recommendations.”

The public meeting on the O&P code proposals will occur June
8 and 9 at CMS headquarters in Baltimore, and final coding changes
will become effective Jan. 1. For more information, visit the CMS
coding home page by clicking
here.