The next round of Medicare’s competitive bidding program is slated to begin in January of 2021, targeting specific knee and spine OTS codes.  Most expect the reduction margins off current reimbursement fee schedules to in the 40-50% range, creating a dramatic financial hit for most physician practices.

Although physician practices are excluded from the actual DME provider application process and are not limited to providing access and service to their patients, they do have to accept the lower fee schedule set for their geographical area as part of the program offering.

Split codes have been in place for several years, but until the competitive bidding program launches in January, providers have not been penalized for using the alternative codes, as reimbursement margins have remained the same.

The main differentiating coding descriptions that impact reimbursement rates has to do with the qualifications of the person performing the fitting, and the amount of custom fitting that has been done on the prefabricated device.

Staff credentials that qualify for providing custom medication service include certified or licensed orthotic fitters, PT, OT, orthotist, and physicians.  Athletic trainers, MA’s, cast technicians, etc., do not meet the criteria, unless they also hold orthotic fitter certification as well.

Custom fitting requires more than adjusting straps or making simple adjustments to the device to correctly fit the patient.  Proof of custom fitting must be documented, and the clinician must provide a detailed account of what was done to custom fit the product and include as part of a SOAP note and within the patient chart.

Certain prefabricated devices on the market do provide the ability to be adjusted and molded, providing the ability to be custom fitted and retain current reimbursement values.  Custom fabricated options, when and where applicable and indicated, could also be utilized to bypass the OTS competitive bidding landscape.

AMG can review staff credentials, documentation procedures, and current product selection criteria, and provide alternative options that can both deliver improved clinical outcomes while retaining or generating new revenue sources, in order to combat the upcoming competitive bidding impact.  Request a free assessment or contact AMG for more information.