New rules for Medicare DME providers and suppliers ramping-up in April-Oct.

Medicare DME continues to restrict and make lives more difficult for providers of orthopedic off-the-shelf (OTS) lumbar and knee braces. New restrictions that begin to ramp-up on April 13, 2022, only apply to OTS braces, such as lumbar braces coded L0648 and L0650.

Other codes such as L0631 and L0637 are not affected by the new rules. We repeat:

The new restrictions do not apply to OTS Prefabricated (custom fitted) orthoses such as the lumbar braces coded L0631 and L0637.

In regard to new restrictions, on April 13, 2022, four states — Florida, New York, Illinois, and California — will be under the new rule requiring all suppliers to obtain a prior authorization before dispensing and billing for an OTS L0648 or L0650 back brace. This will apply to all suppliers, including suppliers located within competitive bid areas.

On July 17, 2022, the prior authorization requirement will begin for the following states: Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington.

And finally, on Oct. 10, 2020, the prior authorization mandate will be nationwide.

The new prior authorization process may cause issues for medical and PT/OT clinic DME suppliers located within competitive bid areas. This is due to these clinics being required to “dispense OTS L0648 and L0650 braces to patients on the same date-of-service they see and treat the patient.”

Clinics that are able to dispense braces such as L0631 and L0637 need not be concerned on the new prior authorization requirement as the new requirement only applies to OTS DME at this time.

Please refer to the three following links for further information:

This link discusses medical and PT/OT clinics required to use the same date of service to dispense a back brace as the one they use to see and treat the patient:

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/dme_physicians_other_pract_factsheet_icn900926.pdf

This link is to the Federal Registry and shows that L0648 and L0650 are both on the list of HCPCS codes that will require a prior authorization:

https://www.federalregister.gov/documents/2022/01/13/2022-00572/medicare-program-updates-to-lists-related-to-durable-medical-equipment-prosthetics-orthotics-and

[Scroll down to table 5]

This link is to the Spinal Orthosis Documentation Checklist:

https://med.noridianmedicare.com/documents/6547796/6558244/Documentation+Checklist+-+Spinal+Orthoses

It will be surprising if these new rules turn out to be easily implemented between the doctor/supplier and the patient.  Time will soon tell how these new procedures will affect, whether greatly or minorly, the ability of the Medicare patient to be able to receive durable medical equipment from their doctor.

If the new prior authorization procedure requirement makes it almost impossible to comply with, then the Medicare patient will suffer from the lack of reasonable and medically necessary care when bracing with codes L0648 and L0650 are therapeutically appropriate.

JAMES C. ANTOS, DC, DABCO, is a long-time Medicare DME consultant who helps chiropractors and other health providers become certified for DME (durable medical equipment) in Medicare. He is with Antos & Associates LLC, and can be reached at antosdmebrace.com, antijm@hotmail.com, or (386) 212-0007.

JOHN DYCUS, is a DME consultant with more than 30 years experience in orthopedic DME, compliance, billing, and competitive bidding with Advisory Board of Directors, Quality MD. He can be reached at (865) 368-0202, or john@dds500.com.