What DMEPOS providers need to know about competitive bidding

  • On January 1st 2021, reimbursement for prefabricated off-the-shelf knee and back braces changed.
  • Medicare reimbursement for prefabricated off-the-shelf knee and back braces included in competitive bidding program has been reduced.
  • All insurance reimbursement for prefabricated off-the-shelf braces (contracted vs. Medicare rates) has been reduced.
  • Physicians & treating practitioners were exempt from participating in the competitive bidding process, however must now accept lower reimbursement for off-the-shelf braces furnished to patients in a competitive bid area
  • Prefabricated custom-fitted and custom fabricated orthoses reimbursement is unaffected by competitive bidding.

Want to learn More About Competitive Bidding?

How does Competitive Bidding affect you?

Physicians and Treating Practitioners – Exemptions

Physicians and treating practitioners (physician assistants, nurse practitioners, and clinical nurse specialists) do not need a competitive bidding contract to receive payment for medically necessary walkers, folding manual wheelchairs, or competitively bid off-the-shelf (OTS) orthotics furnished to their own patients as part of their professional services. Furthermore, a physical or occupational therapist in private practice may furnish competitively bid off-the-shelf back and knee braces without submitting a bid and being awarded a contract, provided that the items are furnished only to the therapist’s own patients as part of the physical or occupational therapy service. Payment to physicians, treating practitioners, and therapists will be made based on the SPA for the item for the CBA where the beneficiary resides.

CBIC Exemptions Information

Reimbursement reductions on off-the-shelf (OTS) knee braces average 30% with some being deeper. Custom-fabricated and Custom-fit reimbursement is unaffected.

Reimbursement reductions on off-the-shelf (OTS) spine braces average 35% with some being deeper. Custom-fit reimbursement is unaffected.

Affected HCPCS Codes

Back Knee
L0450 L1812
L0455 L1830
L0457 L1833
L0467 L1851
L0469 L1852
L0621 L1836
L0623 L1850
L0625  
L0628  
L0641  
L0642  
L0643  
L0648  
L0650  

Knee Bracing HCPCS Codes

Off-The-Shelf (OTS) Custom Fit
L0450 n/a
L0455 L0454
L0457 L0456
L0467 L0466
L0469 L0468
L0621 n/a
L0623 n/a
L0625 n/a
L0628 n/a
L0641 L0626
L0642 L0627
L0643 L0630
L0648 L0631
L0650 L0637

Knee Bracing HCPCS Codes

Off-The-Shelf (OTS) Custom Fit
L1812 L1810
L1830 n/a
L1833 L1832
L1851 L1843
L1852 L1845

Contact Us to Learn More

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More information is available at these links:

CMS Competitive Bidding Home Page: Learn More
Patient Zip Code Lookup: Lookup Tool
DMEPOS Fee Schedule: View Fees
Which codes are Prefab/OTS and which ones are Prefab/Custom fit?  Lookup Off-The-Shelf (OTS) Orthoses
Correct coding for prefabricated orthoses: How to determine OTS v. Custom fit
What code is my back brace? Check on PDAC
CMS Local Coverage Determination (LCD): KNEE ORTHOSES (L33318)
CMS Knee Orthoses – Policy Article: Read More (A52465)
CMS Local Coverage Determination (LCD): SPINAL ORTHOSES: TLSO and LSO (L33790)

Disclaimer

  1. All reimbursement information provided on this website by VQ Orthocare is for informational purposes only. VQ OrthoCare does not guarantee or imply reimbursement for its products. The information herein is provided as a resource for the convenience of healthcare professionals who should use their own professional judgement to utilize and bill for products in the treatment of their patients. The information provided is based upon various sources including billing descriptors, diagnostic codes, CMS policies, announcements and bulletins, PDAC, and information from experienced consultants and DMEPOS suppliers.
  2. Some VQ OrthoCare products are designed to be modified significantly by a trained healthcare professional in order to customize the fit or function of the brace for use by a specific patient. In some cases, the device may be reimbursable as a “custom-fitted brace.” VQ OrthoCare encourages all healthcare professionals to ensure that items billed as “custom-fitted” meet all applicable criteria to warrant billing the relevant specific L-code or codes.
  3. No information provided by VQ OrthoCare should be used as a substitute for the professional judgment of a trained healthcare professional.