DMERC Only – Payment to Providers/Suppliers Qualified to Bill Medicare for Prosthetics and Certain Custom-Fabricated Orthotics

Related Change Request (CR) #: 3373
Medlearn Matters Number: MM3373
Related CR Release Date: October 22, 2004 Related CR Transmittal #: 329 Effective Date: July1, 2005 Implementation Date: July 5, 2005

Provider Types Affected:
Physicians, providers, and suppliers who bill durable medical equipment regional carriers (DMERCs)

Provider Action Needed:
This instruction puts new edits in the Medicare claims processing system to look for specialty codes 51, 52, 53, 55, 56, and 57 when processing claims for prosthetics and custom-fabricated orthotics. These new edits will ensure that those providers specifying Prosthetist and Orthotist (P & O) on their enrollment application are the only entities billing Medicare for P & O supplies.

Claims listing specialty codes other than those just mentioned and representing billings for prosthetics and certain custom-fabricated orthotics will be denied by Medicare. If you did not enter the appropriate specialty code on the National Supplier Clearinghouse (NSC) application, you must reenroll with the NSC.

Any supplier qualified to distribute the prosthetics and customized-fabricated orthotics in question that did not select one of the covered specialties in its initial enrollment can submit a revised CMS 855S enrollment form to the NSC.

Background:
Section 1834(h)(F) of the Social Security Act titled “Special Payment Rules for Certain Prosthetics and Custom-Fabricated Orthotics,” states that no payment will be made for such items unless provided by a qualified practitioner. Currently, DMERCs are processing these claims from all enrolled and approved providers/suppliers without regard to specialty identified on the Enrollment Application Form (Form 855S).

Effective for claims with dates of service of July 1, 2005 or later, DMERCs will process claims for prosthetics and certain customized-fabricated orthotics only when the DMERC provider/supplier files show a specialty code that authorizes billing for prosthetics and these orthotics. The specialties identified as involving orthotics and prosthetics are as follows:
• Medical Supply Company with Certified Orthotist – Specialty Code 51
• Medical Supply Company with Certified Prosthetist – Specialty Code 52
• Medical Supply Company with Certified Orthotist and Prosthetist –
Specialty Code 53
• Certified Orthotist – Specialty Code 55
• Certified Prosthetist – Specialty Code 56
• Certified Orthotist and Prosthetist – Specialty Code 57.

This instruction puts new edits in the claims processing system to look for specialty codes 51, 52, 23, 55, 56, and 57. These new edits will ensure that those providers specifying P & O on their enrollment application are the only entities billing Medicare for P & O supplies.

Claims listing other specialty codes billing for prosthetics and certain custom-fabricated orthotics will be denied, effective for claims with dates of service on or after July 1, 2005.

Any supplier qualified to distribute the prosthetics and customized-fabricated orthotics in question that did not select one of the covered specialties in its initial enrollment can submit a revised CMS 855S enrollment form to the National Supplier Clearinghouse.

Implementation:
The implementation date for this instruction is July 5, 2005.

Additional Information:
The CMS 855 forms may be found at:
http://www.cms.hhs.gov/providers/enrollment/forms/

If you have any questions regarding this issue, please contact your DMERC or intermediary at their toll free number. You may find that number at:
http://www.cms.hhs.gov/medlearn/tollnums.asp

The Medicare Claims Processing Manual (Pub 100-04), Chapter 20 (Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DME/POS), Parenteral and Enteral) Section 130.1 (Provider Billing for Prosthetic and Orthotic Devices), has been revised to include a paragraph regarding editing for P & O claims. The updated manual instructions are included in the official instruction issued to your carrier, and can be found by going to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

Once at that site, scroll down the CR NUM column on the right and click on CR3373.

A comprehensive list of the HCPCS for customized orthotics and prosthetics that need to be used with these specialty codes can also be found at as an attachment to CR3373.