FW: [OANDP-L] 5-year rule and orthotics
Jim Andreassen
Description
Collection
Title:
FW: [OANDP-L] 5-year rule and orthotics
Creator:
Jim Andreassen
Date:
3/26/2003
Text:
Thank you to Walt Gorski for his response to my original post regarding the
5 year rule and orthotics. Also a special thank you to AOPA for their
continued efforts. Please take a moment to read Walt's update on AOPA's
efforts.
Jim Andreassen
President, OPGA
-----Original Message-----
From: Walter Gorski [mailto:<Email Address Redacted>]
Sent: Wednesday, March 26, 2003 7:35 AM
To: Jim Andreassen
Cc: Kathy Dodson
Subject: RE: [OANDP-L] 5-year rule and orthotics
Importance: High
Jim,
The American Orthotic & Prosthetic Association (AOPA) has been working
hard for the past several months to change Medicare's 5-year replacement
rule for orthotic devices. You should know that we have personally met
with the Administrator of the Centers for Medicare and Medicaid (CMS)
and his senior staff on this issue. At that meeting, AOPA was asked by
the Administrator to develop an alternative to the current policy for
CMS' consideration. AOPA's delivered its recommendations to the CMS
Administrator and senior CMS staff yesterday. The DMERC medical
directors were mailed a copy of our recommendations on March 24. Our
recommendations are listed below.
As you know, the DMERCs have determined that the useful lifetime of
orthotic devices is five years. Medicare will pay for a replacement
during this five-year period only if the device is lost, irreparably
damaged or the patient's medical condition changes such that the device
no longer meet's the patient's needs. However, the DMERCs now
distinguish between irreparable damage and damage due to wear. Medicare
coverage of replacement due to irreparable wear during the period of the
device's five-year useful lifetime is currently not covered. The DMERCs
define wear as deteriorization sustained from day-today usage over time,
where a specific event cannot be identified that caused the
deteriorization. Based on the increased call volume AOPA coding experts
have been receiving recently, we believe the DMERCs have stepped up
their enforcement of this regulation.
AOPA has proposed that CMS adopt the same replacement policy toward
orthotic services that now governs prosthetic devices. This prosthetic
policy was enacted in the Benefits Improvement and Protection Act of
2000 (BIPA). AOPA believes that having one consistent policy covering
the replacement of both orthotic and prosthetic devices and components
is a reasonable solution to the current situation and is in the best
interests of Medicare beneficiaries who must rely on either orthotic and
prosthetic services.
We will be working diligently over the next several months to urge CMS
adopt this policy recommendation.
If you have any questions about AOPA's activity on this topic or any of
our other many legislative and regulatory issues, please contact me at
571-431-0809.
Sincerely,
Walt Gorski
AOPA Director of Legislative Affairs
------------------------
AOPA RECOMMENDATIONS TO CMS ON THE REPLACEMENT OF ORTHOTIC SERVICES
------------------------
Payment shall be made for the replacement of orthotic devices or the
replacement of any part of such devices without regard to continuous use
or useful lifetime restrictions if an ordering physician determines that
the provision of a replacement device, or a replacement part of such
device, is necessary because of any of the following:
--A change in the physiological condition of the patient;
--An irreparable change in the condition of the device, or in part
of the device;
--The condition of the device or part of the device requires
repairs and the cost of such repairs would be more than 60
percent of the cost of a replacement device, or as the case may be, of
the part being replaced.
If a physician determines that a replacement device, or replacement
part, is necessary: 1) such determination shall be controlling; and, 2)
such replacement device or part shall be deemed to be reasonable and
necessary for purposes of section 1862(a)(1)(A); except that if the
device, or part, being replaced is less than 3 years old (calculated
from the date on which the beneficiary began to use the device or part),
the Secretary may also require confirmation of the necessity of the
replacement device or replacement part.
-----Original Message-----
From: Jim Andreassen [mailto:<Email Address Redacted>]
Sent: Monday, March 24, 2003 1:54 PM
To: <Email Address Redacted>
Subject: [OANDP-L] 5-year rule and orthotics
Peggy Walker, who is a consultant for OPGA/OPGA recently met with the
Region C Medical Review team and would like me to pass on the following
information regarding orthotic billing and the 5-year rule. Please read
her comments. In a meeting with the Region C Medical Review team on
Friday the 21st of March the 5 year rule as it applies to the Orthotic
codes was discussed. The reason for the written reminder of the rule was
given. The high increase of duplication in billing of these codes was
noted as a rising problem. In some instances one patient was billed for
4 to 8 knee braces within a four month time. The clarification was given
that if the patient has a need for a replacement due to a documented
change in condition (weight gain or loss; change in any type for need
for a different type of item that is fully documented in physicians'
records will be reviewed.) If an item is torn beyond repair and cost of
repair is greater than cost of a new item additional documentation will
be reviewed and in some instances pictures would help. Please call Peggy
at 800-401-3643 if you need further clarification on this issue. You
just need to be careful of the words normal wear and tear. Make sure
there is good documentation in your records as well as physicians and
you will need an order for the replacement.
As stated above, feel free to give Peggy a call with any questions.
Jim Andreassen
President, OPGA
Phone: 800-214-6742
Fax: 888-449-0610
email: <Email Address Redacted>
HAVE YOU REGISTERED FOR THE HEARTLAND CONFERENCE 2003? REGISTER ONLINE
AT WWW.HEARTLAND2003.COM OR CALL 800.642.6065! MAY 28-31, WATERLOO, IA.
5 year rule and orthotics. Also a special thank you to AOPA for their
continued efforts. Please take a moment to read Walt's update on AOPA's
efforts.
Jim Andreassen
President, OPGA
-----Original Message-----
From: Walter Gorski [mailto:<Email Address Redacted>]
Sent: Wednesday, March 26, 2003 7:35 AM
To: Jim Andreassen
Cc: Kathy Dodson
Subject: RE: [OANDP-L] 5-year rule and orthotics
Importance: High
Jim,
The American Orthotic & Prosthetic Association (AOPA) has been working
hard for the past several months to change Medicare's 5-year replacement
rule for orthotic devices. You should know that we have personally met
with the Administrator of the Centers for Medicare and Medicaid (CMS)
and his senior staff on this issue. At that meeting, AOPA was asked by
the Administrator to develop an alternative to the current policy for
CMS' consideration. AOPA's delivered its recommendations to the CMS
Administrator and senior CMS staff yesterday. The DMERC medical
directors were mailed a copy of our recommendations on March 24. Our
recommendations are listed below.
As you know, the DMERCs have determined that the useful lifetime of
orthotic devices is five years. Medicare will pay for a replacement
during this five-year period only if the device is lost, irreparably
damaged or the patient's medical condition changes such that the device
no longer meet's the patient's needs. However, the DMERCs now
distinguish between irreparable damage and damage due to wear. Medicare
coverage of replacement due to irreparable wear during the period of the
device's five-year useful lifetime is currently not covered. The DMERCs
define wear as deteriorization sustained from day-today usage over time,
where a specific event cannot be identified that caused the
deteriorization. Based on the increased call volume AOPA coding experts
have been receiving recently, we believe the DMERCs have stepped up
their enforcement of this regulation.
AOPA has proposed that CMS adopt the same replacement policy toward
orthotic services that now governs prosthetic devices. This prosthetic
policy was enacted in the Benefits Improvement and Protection Act of
2000 (BIPA). AOPA believes that having one consistent policy covering
the replacement of both orthotic and prosthetic devices and components
is a reasonable solution to the current situation and is in the best
interests of Medicare beneficiaries who must rely on either orthotic and
prosthetic services.
We will be working diligently over the next several months to urge CMS
adopt this policy recommendation.
If you have any questions about AOPA's activity on this topic or any of
our other many legislative and regulatory issues, please contact me at
571-431-0809.
Sincerely,
Walt Gorski
AOPA Director of Legislative Affairs
------------------------
AOPA RECOMMENDATIONS TO CMS ON THE REPLACEMENT OF ORTHOTIC SERVICES
------------------------
Payment shall be made for the replacement of orthotic devices or the
replacement of any part of such devices without regard to continuous use
or useful lifetime restrictions if an ordering physician determines that
the provision of a replacement device, or a replacement part of such
device, is necessary because of any of the following:
--A change in the physiological condition of the patient;
--An irreparable change in the condition of the device, or in part
of the device;
--The condition of the device or part of the device requires
repairs and the cost of such repairs would be more than 60
percent of the cost of a replacement device, or as the case may be, of
the part being replaced.
If a physician determines that a replacement device, or replacement
part, is necessary: 1) such determination shall be controlling; and, 2)
such replacement device or part shall be deemed to be reasonable and
necessary for purposes of section 1862(a)(1)(A); except that if the
device, or part, being replaced is less than 3 years old (calculated
from the date on which the beneficiary began to use the device or part),
the Secretary may also require confirmation of the necessity of the
replacement device or replacement part.
-----Original Message-----
From: Jim Andreassen [mailto:<Email Address Redacted>]
Sent: Monday, March 24, 2003 1:54 PM
To: <Email Address Redacted>
Subject: [OANDP-L] 5-year rule and orthotics
Peggy Walker, who is a consultant for OPGA/OPGA recently met with the
Region C Medical Review team and would like me to pass on the following
information regarding orthotic billing and the 5-year rule. Please read
her comments. In a meeting with the Region C Medical Review team on
Friday the 21st of March the 5 year rule as it applies to the Orthotic
codes was discussed. The reason for the written reminder of the rule was
given. The high increase of duplication in billing of these codes was
noted as a rising problem. In some instances one patient was billed for
4 to 8 knee braces within a four month time. The clarification was given
that if the patient has a need for a replacement due to a documented
change in condition (weight gain or loss; change in any type for need
for a different type of item that is fully documented in physicians'
records will be reviewed.) If an item is torn beyond repair and cost of
repair is greater than cost of a new item additional documentation will
be reviewed and in some instances pictures would help. Please call Peggy
at 800-401-3643 if you need further clarification on this issue. You
just need to be careful of the words normal wear and tear. Make sure
there is good documentation in your records as well as physicians and
you will need an order for the replacement.
As stated above, feel free to give Peggy a call with any questions.
Jim Andreassen
President, OPGA
Phone: 800-214-6742
Fax: 888-449-0610
email: <Email Address Redacted>
HAVE YOU REGISTERED FOR THE HEARTLAND CONFERENCE 2003? REGISTER ONLINE
AT WWW.HEARTLAND2003.COM OR CALL 800.642.6065! MAY 28-31, WATERLOO, IA.
Citation
Jim Andreassen, “FW: [OANDP-L] 5-year rule and orthotics,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/220806.
