by Jared Staheli
June 18th, 2015
See § 01 for definition of provider.
These items consist of all prosthetic and orthotic devices excluding parenteral/enteral nutritional supplies and equipment and intraocular lenses.
Prosthetics and orthotic devices are included in the Part A PPS rate unless specified as being outside the rate. For SNFs, customized prosthetic devices that are not included in the Part A PPS rate and which may be billed separately are identified in the SNF HCPCS HELP file. Click here to access the file electronically. The file is updated as CMS determines appropriate. It describes HCPCS codes for services included in Part A consolidated billing, the services separately billable by the SNF or supplier under Part B for Part A and/or Part B inpatients, and services that may be billed by a supplier but not by SNF. If these latter services are billed by the SNF, no additional payment will be made. If the SNF or hospital wants also to be a supplier, they must enroll with National Supplier Clearinghouse and bill the DMERC. However, the DMERC will not separately pay for items of DME provided to a beneficiary in a Part A SNF stay.
Those items or services that are considered outside the PPS rate may be billed by the supplier in the case of a SNF or hospital to the FI, or if furnished by a qualified outside entity, that entity may bill its normal contractor.
The SNFs, hospitals, or other entities that furnish prosthetic and/or orthotic devices to their patients for whom Part A benefits are not payable (i.e., no Part A entitlement or benefits exhausted) may bill for such items, assuming other billing requirements are met.
NOTE: Items such as catheters and ostomy supplies are excluded from the fee schedule when billed by HHAs for patients under a plan of care. In this situation, HHAs bill for these items as supplies under revenue code 0270. Effective with items furnished on or after January 1, 1994, the fee schedules for ostomy, tracheostomy, and urological supplies are calculated using the same method used to calculate the purchase fee schedules for inexpensive or other routinely purchased DME.
HCPCS codes A4214, A4310 through A4330, A4338 through A4359, and A5102 through A5114 are excluded from the fee schedule when billed by hospitals along with an ASC service. Hospitals bill for these items as supplies, under revenue code 0272. In addition, HCPCS codes A5119 through A5131 are excluded from the fee schedule unless they are submitted with ostomy related ASC procedure codes 44340 through 44346, 44380, 44382, 44388 through 44392, or 50953 through 50961.
In all other circumstances, including HHAs billing for patients not under a plan of care, SNFs, CORFs, OPTs, and hospitals bill these items as prosthetics and orthotics under code 0274, along with the relevant HCPCS code.
DMERCs only – For all states that have licensure/certification requirements for provision of prosthetics and/or orthotics, DMERCs shall process claims for Prosthetics and Certain Custom-Fabricated Orthotics only when the following specialty codes are forwarded to the DMERCs from the NSC. The specialty codes are:
• 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;
• Ocularist – Specialty Code B5; and
• All Physician Specialty Code listed in this manual [IOM] Chapter 26, §10.8.2
These specialties shall be licensed or certified by the state when applicable. These specialties shall bill for Medicare services when State law permits such entity to furnish a prosthetic or orthotic.
Claims billed by other specialty codes for prosthetics and certain custom-fabricated orthotics shall be denied.