“I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men.”

Granted, the insurance industry reforms in the ACA are a positive for the O&P industry, but the creation and proliferation of Accountable Care Organizations, O&P inclusion in the “essential health benefits package” and the acceleration of fraud investigation and provider audits are all issues whose impact has yet to be fully determined for the O&P community.  As a whole, I find it strange that at a time when the Affordable Care Act is to be taken up by the Supreme Court in just a few weeks that the President would choose to basically ignore the largest domestic policy “victory” in the first three years of his presidency.  The President made passing mention of his willingness to make tough choices on entitlement programs in order to get a larger deal to put America back on sound financial footing, but otherwise ignored the issue altogether. 

The President did endorse using revenues that were previously earmarked for the wars in Iraq and Afghanistan to pay for an extension of the payroll tax cut extension, the “doc fix” and other infrastructure initiatives. The payroll tax cut is tied to the “doc fix”, which the President again chose not to mention.  Funding for the 2-month extension of the doc fix expires on March 1st and Congress is looking for offsets to pay for the year long extension. In the search for these offsets, Congress could look for other health care related savings from DMEPOS or Medicare providers in the form of rate cuts or additional fees. 

My takeaway from the President’s speech last night was that he obviously plans to run against the most unpopular congress in American history this fall during the Presidential election.  He listed issue after issue of his policy proposals, many of which have atleast some bipartisan support, but knowing full-well that very little, if any, of his agenda has any chance of becoming law in this heated election year. He plans to tell the American public that the corrupt institution of congress is the reason for our dire economic situtation and that he is best positioned to fix the problem.  Republican presidential candidates will likely make the argument that we should use the past three years as a guide to how well the President is able to change how congress works.

O&P professionals must remain vigilant in the face of continued budget cuts to health care related programs and continue to focus on providing quality care to our patients. As a profession, we need to focus on quantifying our value to the health care system overall, only then can we start to become part of the solution to the runaway cost increases of entitlement programs crippling the federal budget. 

Contact OPGA for help contacting your federal and state elected officials on the importance of O&P being included in the “essential health benefits package”, information on Accountable Care Organizations and other important legislative and regulatory issues that will have an dramatic affect on the future of the O&P profession.

The first case is the challenge to the constitutionality of the Patient Protection Affordable Care Act (PPACA, Obamacare).  The court is slated to rule on the individual mandate, which mandates all individuals obtain health insurance or pay a fine beginning in 2014, as well as the expansions of Medicaid enrollment to 133% of the Federal Poverty Level. If the court rules that it is unconstitutional for the federal government to essentially force states to increase their enrollment criteria, it would be a severe blow to the federal government having the right to require certain benefit coverages, or check reimbursement rates, etc, essentially allowing states to receive federal matching funds and be free to do whatever they please with them to treat their Medicaid patients.  Considering that orthotics and prosthetics are not a mandated benefit under Medicaid, this could create an environment ripe for states to solve budget holes by cutting non-mandated benefits like O&P.  Courts have issued split rulings on the constitutional argument related to the Affordable Care Act, 3-3 to date. Oral arguments are expected on the challenge to the Affordable Care Act beginning in mid-March.

The second, less noteworthy case is, Douglas v. Independent Living Center of Southern California, which will decide whether Medicaid beneficiaries and providers have the right to sue the state of California for cutting reimbursement rates to the point that they say violate federal rules requiring HHS to provide reasonably attainable care.  The Obama Administration weighed in on the California case in October 2011, arguing that only the federal government has the right to monitor and approve such changes to the state/federal program. Courts have ruled in favor of the state of California to date.

Taken together, the rulings of the Supreme Court on these two cases could potentially have a dramatic impact on the Medicaid program as a whole, and whether orthotics and prosthetics continue to be a covered benefit in many states.  MORE

OPGA Government Relations will continue to monitor these cases and provide updates when appropriate.  These cases only underscore the importance of orthotics and prosthetics benefits being included in “essential health benefits packages” across the country.  Contact OPGA for help contacting your state legislators or insurance commissioners to speak of the importance of orthotics and prosthetics and the positive budget impact of the quality, professional services provided by O&P professionals in your state.

Frequently Asked Questions regarding deadlines for ASC X12 Version 5010

1. Q: Will submitters who have not tested 5010 be able to continue to submit 4010 claims after January 1st while their transition plan is being reviewed by the Medicare Administrative Contractors (MACs)? If the plan is approved how much grace time will be granted? 

A: Submitters who have not tested will need to submit their transition plan within 30 calendar days of the date of the notice from the MAC. Those who submit a transition plan by the deadline will have until April 1, 2012 to complete their transition to the 5010 formats.

2. Q: What will happen if submitters don’t submit a transition plan? Will their 4010 claims be rejected as of the 31st day?

A: If no transition plan is submitted, Medicare FFS may direct the MACs to reject 4010 claims. The MACs have not been directed to reject 4010 claims at this time.

3. Q: Is Medicare going to release information about exactly what a transition plan will look like?

A: Medicare FFS will not specify the format of the transition plan. Submitters should outline the steps they have taken and the steps they still need to take to successfully achieve compliance with the updated version of the transactions.

4. Q: Are the 30 day deadlines stated in the Medicare FFS announcement working or calendar days and does the 30 day clock start with notification or on January 1, 2012?

A: The 30 day deadlines are calendar days and the 30 day clock starts with the date of the notification from the MAC.

5. Q: Will the MACs be able to accept a mix of 5010 and 4010 claims during the 90 day non-enforcement period?

A: Yes, MACs will be able to accept a mix of 5010 and 4010 claims during the 90 day non-enforcement period.

6. Q: Who notifies providers that have passed 5010 testing and submit directly to Medicare? What is the difference between a submitter and a provider?

A: The MACs notify providers that submit directly (without the use of a submitter) to Medicare. A submitter is a clearinghouse, vendor or biller that submits to Medicare on behalf of one or more providers. The Medicare FFS 90 Day Discretionary Enforcement announcement requires submitters to test with their MACs, submitters to take action in regards to this plan and submitters to send in their transition plans to the MACs.

For more information regarding the transition to the 5010, click here.

• L6715 TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S), INITIAL ISSUE OR REPLACEMENT
• L6880 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS, ANY GRASP PATTERN OR COMBINATION OF GRASP PATTERNS, INCLUDES MOTOR(S).

HCPCS code L6715 describes multiple articulating digit(s) (fingers and/or thumb) which are used on initial issue when paired with a partial hand base procedure code (L6000, L6010, L6020).  The articulating digit(s) can also be used as a “replacement digit(s)” with the use of the RB modifier as part of a prosthetic repair.  The following base procedure codes include a custom fabricated socket.

• L6000  PARTIAL HAND, THUMB REMAINING   
• L6010 PARTIAL HAND, LITTLE AND/OR RING FINGER REMAINING                               
• L6020 PARTIAL HAND, NO FINGER REMAINING 

HCPCS Code L6025 (TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICE) describes a complete prosthesis.  This base procedure code includes all necessary components.  This base procedure code includes a custom fabricated socket.   The use of L6715 on initial issue will be denied as unbundling.

HCPCS code L6880 describes a complete hand prosthesis, which consists of the terminal device, all articulating digits and motors.  This base procedure code does not include a custom fabricated socket.  This base procedure code includes all necessary components.   The use of L6715 on initial issue will be denied as unbundling.

HCPCS code L7499 (UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used for  the billing of any additional features or components, programming, adjustment, etc. with L6025 or L6880 as these codes are considered all-inclusive.  The use of L7499 on initial issue will be denied as unbundling.

The above information was gathered from CGS, please click here for additional information.

L2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL
A pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.

L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTOUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
A multiligamentous ankle support provides control of the ankle joint between the medial and lateral malleoli while allowing for dorsiflexion and plantar flexion. This off-the-shelf ankle support includes a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation. This, in conjunction with wrap-around straps and the inherent gauntlet design, offers areas of multiligamentous support as described by the code. There are no additional HCPCS codes for this type of prefabricated ankle orthosis.

L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED
An Ankle Foot Orthosis (AFO) provides ankle control for patients with musculoskeletal or neuromuscular dysfunction. The AFO is designed to provide rigid immobilization of the ankle-foot complex in the sagittal, coronal, and transverse planes. The custom fabricated solid ankle AFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. The proximal border of an Ankle Foot Orthosis (L1960) shall extend to a height no greater than 1.5 inches distal to the apex of the head of the fibula.

Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 (ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES  FITTING AND ADJUSTMENT) are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification Matrix of the DME Coding System (DMECS) maintained on the PDAC website, https://www.dmepdac.com/dmecsapp/do/search. Products which have not received coding verification review from the PDAC must be billed with code A9270. MORE

The revised Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories), physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. The revised ABN replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). See the revised ABN manual instructions below for detailed instructions on mandatory and voluntary use of the revised ABN.

Note: Skilled nursing facilities (SNFs) must use the revised ABN for items/services expected to be denied under Medicare Part B only.

September 20, 2011: Extension of mandatory use date for REVISED ABN, FORM CMS-R-131, posted for download on May 16, 2011. Mandatory use date: January 1, 2012

The latest version of the ABN (with the release date of 3/2011 printed in the lower left hand corner) is now available for immediate use and can be accessed via the link below. In order for providers and suppliers to have time to transition to using the newly posted notice, mandatory use of this version begins on January, 1 2012. All ABNs with the release date of 3/2008 that are issued on or after January 1, 2012 will be considered invalid.

Updated forms and instructions can be found here

CMS Releases 2012 Medicare Fee Schedule for O&P — Last month CMS released the 2012 fee schedule for DMEPOS Medicare providers. Effective January 1, 2012, O&P providers will see a 2.4% increase in their reimbursement rates. The fee schedule is tied to increases in the consumer price index for urban communities and is calculated annually.  Please note the failure of the Joint Congressional Committee on Deficit Reduction earlier this year will bring an automatic 2% cut to reimbursement rates in 2013 if no other legislative fix is initiated in 2012. Along with the announcement of the fee schedule increase, CMS also released updated HCPCS code information, deleting the following codes: E0571, L3966, L4380, L1500, L3968, L5311, L1510, L3969, L7266, L1520, L3970, L7272, L3972, L3964, L3974, L7274, L3965, L750. More information on the CMS release can be found here

Still No ‘Doc Fix’, Political Squabbling Continues After Senate Bill Passes    The House has rejected the bipartisan agreement reached in the Senate over the weekend that would have extended for two months the Social Security payroll tax cut and unemployment insurance, while averting a 27% reimbursement cut to physicians beginning January 1st. Both Republicans and Democrats have turned up the spin machine to talk about the failure of the other, meanwhile, the provisions listed above, that affect 95% of Americans, still weigh in the balance. The Senate has adjourned for the holidays, leaving the House to decide whether to pass the bipartisan Senate bill, or risk not extending these important provisions scheduled to expire on January 1st, 2012.  Read the key differences between the House and Senate bills here.

UPDATE: House Republicans appear to have relented and agreed to the 2 month extension of the important tax, unemployment and doc fix reimbursement provisions included in the bipartisan agreement passed by the Senate earlier this week.  The House will likely pass a similar version of the bill that will set up a full conference committee to negotiate a full year extension early next year. MORE

Update: CMS said Monday it would instruct its claims administrators to hold off processing claims for the first 10 business days of January to allow more time to end the impasse, which would last through January 17th.

HHS Punts Tough Decisions on ‘Essential Benefits’ Package Makeup to States  After spending more than a year “gathering input” from the Department of Labor, Institute of Medicine and industry stakeholders, the Department of Health and Human Services has decided to give individual states “wide latitude” in determining which benefits will be given “essential benefit” status by insurance companies when creating the minimum plans that can be sold on “state-based health exchanges” beginning in 2014.  The guidance, which also delays inevitably final federal rules on the issue, provides four choices for states to use in creating their benchmark plans:

• One of the three largest small group plans in the state by enrollment;
• One of the three largest state employee health plans by enrollment; 
• One of the three largest federal employee health plan options by enrollment;
• The largest HMO plan offered in the state’s commercial market by enrollment. 

More information about the new HHS guidance on the essential benefits package can be found here.

Medicaid RAC’s: More Challenges on the Horizon for O&P Providers (O&P Business News) One of the most aggressive tactics used by the Centers for Medicare and Medicaid Services (CMS) to recover overpayments under the Medicare program is the use of Recovery Audit Contractors (RACs). These Medicare contractors are incentivized financially to deny claims and have been an ongoing source of concern and frustration for health care providers in general, and O&P professionals in particular. RACs tend to target areas that are identified in reports issued by the Department of Health and Human Services (HHS) Office of Inspector General (OIG), which involve areas susceptible to high levels of fraud and abuse, such as in the DME industry. There are now permanent Medicare RACs in all 50 states and these RACs have already begun to address the DME and O&P fields. They are about to be joined by 50 additional auditors — the Medicaid RACs. MORE

Supreme Court Announces it will Hear Oral Arguments in ACA Case – The Supreme Court announced late last week they will hear oral arguments in the case challenging the constitutionality of the Affordable Care Act’s “individual mandate” provision in March of 2012.  Five hours, a nearly unparallelled amount in modern times, of debate has been scheduled and will be split into four sections:

1.) Debate on whether legal action is premature since the individual mandate and penalties won’t go into effect until 2014. 2.) Debate on the constitutionality of the individual mandate provision. 3.) Whether striking the individual mandate necessitates striking the entire Affordable Care Act and all related provisions. 4.) Whether the law goes too far in cohercing states to comply by choking off federal funding to existing programs.

With oral debate now set, a likely ruling by the Court will come in the summer of 2012, right in the middle of the President’s re-election campaign.  MORE

Congressional Republicans propose to cut nearly $38 billion from the Affordable Care Act, increase premiums for wealthy Medicare beneficiaries and change the formula by which unemployment benefits are calculated in exchange for a 2 year ‘doc fix’ and one year extensions of the other provisions.  Democrats recently backed off their proposal to raise taxes on Americans making more than $1 million a year, but still advocate using more than $40 billion in projected savings from the early removal of troops from Iraq.  Additional cuts to Medicare provider reimbursements are not currently part of the negotiations, so at the moment O&P providers are being spared the budget ax. With both sides eager to adjourn for their extended holiday break, the spending bill will be voted on and passed today to avert government shutdown at midnight tonight.  An agreement funding the rest of these must-pass items could be reached today or over the weekend.  A temporary 2 month extension of the payroll tax cut, unemployment benefits and the “doc fix” is being prepared in the event negotiators cannot reach a longterm agreement before adjournment.  MORE

House Passes Doc Fix, Payroll Tax Extension in Spending Bill — Last night the House of Representatives passed a bill to avert a 27% cut to physicians appropriately named, “doc fix”, also known as the sustainable growth rate, a formula used to calculate reimbursement payments to physicians serving Medicare patients. The doc fix, extensions of unemployment insurance and Social Security payroll tax deduction for individuals were all included as part of the must pass, year-end spending bill that both sides have been negotiating for months.  The Democratically-controlled Senate quickly announced their disapproval of the House version of the spending bill, leaving both sides scrambling to blame the other for playing politics with the most recent continuing resolution funding the government scheduled to run out on Friday. At present, the main sticking point seems to be how to pay for these costly additions to the spending bill, orthotics and prosthetics have not been included in any of the offsets discussed publicly by the House or Senate. MORE