LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2014-05 MM8730 Related CR 8730 State Licensure

KYDEX-PRO

STRONGER

SAFER

LEEDerGroup.com

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services REVISED products from the Medicare Learning Network® (MLN) Basic Medicare Information for Providers and Suppliers� Guide (ICN005933), Downloadable

  • MLN Matters® Number: MM8730 Related Change Request (CR) #: CR 8730
    Related CR Release Date: May 16, 2014 Effective Date: March 3, 2014 Related CR Transmittal #: R1385OTN Implementation: June 17, 2014 Additional States Requiring Payment Edits for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers of Prosthetics and Certain Custom-Fabricated Orthotics. Update to CR3959 and CR8390.
  • Provider Types Affected
    This MLN Matters® Article is intended for DMEPOS suppliers in Alabama, Arkansas, Florida, Georgia, Illinois, Kentucky, Mississippi, New Jersey, Ohio, Oklahoma, Rhode Island, Tennessee, Texas, Washington, North Dakota, Iowa, and Pennsylvania who bill Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Prosthetics and Orthotics (P&O) provided to Medicare beneficiaries.
  • Provider Action Needed
    The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8730 to announce the three additional states that require the use of a licensed/certified orthotist or prosthetist for furnishing of P&O. The states are North Dakota, Iowa, and Pennsylvania.
    Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association.
    Page 1 of 3MLN Matters® Number: MM8730
    Related Change Request Number: 8730
  • Background
    CMS issued Transmittal 656, CR3959 on August 19, 2005. This CR instructed Durable Medical Equipment Regional Contractors (DMERCs, since changed to DME MACs) to implement claims processing edits to ensure compliance with CMS regulations found at 42 CFR Section 424.57©(1). Such regulations require DMEPOS suppliers wishing to bill Medicare to operate their business and furnish Medicare-covered items in compliance with all applicable Federal and State licensure and regulatory requirements. As a result of CR3959, the DME MACs implemented an edit which was programmed to deny claims for prosthetics and certain custom-fabricated orthotics when those items were furnished by personnel who were not licensed/certified as a orthotist or prosthetist by the State in which they practice. At the time CR3959 was issued and the DME MACs implemented the edit, there were nine states requiring the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics. Since that time, five additional states have instituted requirements for the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics. These five states are Arkansas, Georgia, Kentucky, Mississippi, and Tennessee. CR8390 instructed the DME MACs to revise the programming edits so that Arkansas, Georgia, Kentucky, Mississippi, and Tennessee are added to the logic, in accordance with CR3959. CR8730 requires DME MACs to revise the programming edits so that North Dakota, Iowa, and Pennsylvania are added to the logic, in accordance with CRs 3959 and 8390. In the 17 states that have indicated that provision of prosthetics and orthotics must be made by licensed/certified orthotist or prosthetist, Medicare payment may only be made for prosthetics and certain custom-fabricated orthotics when furnished by physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel, and prosthetics personnel. These specialties will bill for Medicare services when State law permits such entity to furnish an item of prosthetic or orthotic using the following codes:
    • Medical Supply Company with Orthotics Personnel – Specialty Code 51;
    • Medical Supply Company with Prosthetics Personnel – Specialty Code 52;
    • Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53;
    • Orthotics Personnel – Specialty Code 55;
    • Prosthetics Personnel – Specialty Code 56;
    • Orthotics Personnel, Prosthetics Personnel, and Pedorthists – Specialty Code 57;
    • Physical Therapist – Specialty Code 65;
    • Occupational Therapist – Specialty Code 67;
    • Pedorthic Personnel – Specialty Code B2;
    Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
    CPT only copyright 2013 American Medical Association.
    Page 2 of 3MLN Matters® Number: MM8730
    Related Change Request Number: 8730
    • Medical Supply Company with Pedorthic Personnel – Specialty Code B3;
    • Ocularist – Specialty Code B5; and • All Physician Specialty Code listed in the “Medicare Claims Processing Manual,” Chapter 26, Section10.8.2, which is available at http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf on the CMS website.
    If a supplier is located in one of the applicable states, that supplier must be properly enrolled with the National Supplier Clearinghouse (NSC) to ensure the correct specialty code(s) is on file in order to submit a claim to Medicare for the prosthetics and custom-fabricated orthotics. Failure to be properly enrolled will result in the claim being denied. A copy of the State license should be sent to the NSC if the supplier is in one of the seventeen states requiring a license. If a supplier should need to update its’ file with the correct specialty, the supplier must ubmit a “Change of Information� on Form CMS-855S to the NSC along with all applicable licenses or certifications. That form is available at http://www.cms.gov/Medicare/CMS-
    Forms/CMS-Forms/downloads/cms855s.pdf on the CMS website. The NSC is responsible for maintaining a central data repository for information regarding suppliers. The NSC transmits this repository to the four DME MACs. The effective date for the new or revised specialty code for P&O claims will be the date the NSC issues the specialty code. The new or revised specialty code will not be applied retroactively.
    Additional Information
    The official instruction, CR8730 issued to your DME MAC regarding this change, is available at http://www.cms.gov/Regulations-and-
    Guidance/Guidance/Transmittals/Downloads/R1385OTN.pdf on the CMS website. To review the article related to CR8390, visit http://www.cms.gov/Outreach-and-
    Education/Medicare-Learning-Network-
    MLN/MLNMattersArticles/Downloads/MM8390.pdf on the CMS website.
    To review the CR3959, visit http://www.cms.gov/Outreach-and-Education/Medicare-
    Learning-Network-MLN/MLNMattersArticles/Downloads/MM3959.pdf on the CMS
    website.
    If you have any questions, please contact your DME MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-
    Learning-Network-MLN/MLNMattersArticles/index.html under – How Does It Work.
    Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
    CPT only copyright 2013 American Medical Association.
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