Why was spinal orthoses chosen to be a topic?
Spinal orthoses was selected as a CBR topic because the Office of Inspector General (OIG) determined that improper payment rates are high for suppliers of orthotic braces. The OIG found that many services billed were not medically necessary and the documentation submitted did not meet Medicare criteria. For more details, see the following web links:
Does receiving a CBR mean that I am referring these items incorrectly?
Receiving a CBR is not necessarily indicative of incorrect practices; however, it does mean that your referral patterns are different from your peers. There can be many reasons your patterns may vary, including region, subspecialty, and patient acuity. If you still have questions and/or concerns after reviewing your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Should I be concerned about being audited since I received a CBR?
The CBR team does not conduct audits nor have access to medical documentation needed to perform audits of claims. The purpose of CBRs is to inform providers and/or suppliers about their billing and payment patterns. It may be beneficial, however, for you to conduct self-audits from time to time. Resources that can help with setting up an audit process are located on our CBR website page at the link titled, Self-Audit Help.
Where can providers and/or suppliers find additional information about CBR201802?
Providers and/or suppliers may benefit from the explanations of the Tables in the CBR, which are found at the web link titled, CBR201802 Statistical Debriefing. Additionally, the links for the references and resources used in this CBR are located at CBR201802 Recommended Links.
How does Medicare define braces?
According to the Medicare Benefit Policy Manual, braces are “rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.” More information about coverage of braces is found at the web link titled, Medicare Benefit Policy Manual, Chapter 15, Section 130.
When is a prefabricated orthosis considered to be custom fitted?
Custom-fitted orthosis must meet two requirements. “Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment. This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.” More information is available at the link titled, Correct Coding – Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correction.
When is a provider considered to have specialized training?
According to Appendix C of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Quality Standards, “Individuals supplying the item(s) set out in this appendix must possess specialized education, training, and experience in fitting, and certification and/or licensing.” They can also be an individual specially trained to custom fit beneficiaries that have a medical need for an orthosis. For more information, select the following link: DMEPOS Quality Standards, Appendix C.
What is minimal self adjustment?
According to the Electronic Code of Federal Regulations (e-CFR), Title 42, 414.402, “Minimal self-adjustment means an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and does not require the services of a certified orthotist (that is, an individual certified by either the American Board for Certification in Orthotics and Prosthetics, Inc., or the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.” Details are available at the link, e-CFR, Title 42, Chapter IV, 414.402.
How often can an orthosis be replaced?
Per the Medicare Claims Processing Manual, “Expenses for replacement required because of loss or irreparable damage may be reimbursed without a physician's order when, in the DME MAC’s judgment, the equipment as originally ordered, considering the age of the order, still fills the patient's medical needs. However, claims involving replacement equipment necessitated because of wear or a change in the patient's condition must be supported by a current physician's order.” For more information about orthosis replacement, select this link: Medicare Claims Processing Manual, Chapter 20, Section 50. (For information pertaining to payment for equipment replaced under a warranty, please see the Medicare Benefit Policy Manual, Chapter 16, Section 40.4).
Are repairs to orthoses covered?
According to the Medicare Benefit Policy Manual, “Repairs to equipment which a beneficiary owns are covered when necessary to make the equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess...When billing for repairs, include the HCPCS code and date of purchase of the item being repaired (if the HCPCS code is not available, include the manufacturer’s name, product name, and model number of the equipment), the manufacturer’s name, product name, model number, and supplier price list amount of the repair item provided, and the justification of the repair. Use the RB modifier on DMEPOS claims to indicate replacement parts of a DMEPOS item (base equipment/device) furnished as part of the service of repairing the DMEPOS item (base equipment/device).” For guidelines on repair of orthoses, select the following web link: Medicare Benefit Policy Manual Chapter 15, Section 110.2(A) (B) (C).
Does the MD have to include the exact brand of orthosis in notes (or detailed written order)?
According to the Medicare Program Integrity Manual, “All DMEPOS items…require detailed written orders prior to billing. Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen-and-ink" document. The written order must be sufficiently detailed, including all options or additional features that will be separately billed or that will require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base), or a brand name/model number. All orders must clearly specify the start date of the order.” More information can be found at the following links:
- Medicare Program Integrity Manual, Chapter 5, Section 5.2.3
- e-CFR Title 42, Section 410.38(c)(4), 410.38(g)(2)
As a physician practice that orders braces, why can't proof of delivery (POD) be accepted if the provider states the patient is getting the item before they leave?
According to the Medicare Program Integrity Manual, “Suppliers are required to maintain proof of delivery documentation in their files. Proof of delivery documentation must be maintained in the supplier’s files for 7 years (starting from the date of service).” Medicare contractors have “the authority to request any information necessary to determine the amounts due. This includes proof of delivery in order to verify that the beneficiary received the DMEPOS item and thus to determine the amounts due to the provider. Proof of delivery is also one of the supplier standards as noted in e-CFR 42, Section 424.57(c)(12).” Anyone can accept delivery and sign for DMEPOS on behalf of the beneficiary as long as they are not the supplier, employees of the supplier or anyone that may have a financial interest in the delivery of the item. The supplier may deliver an item to the hospital or the beneficiary’s home 2 days prior to discharge. Please select the links below for detailed information:
How was the data obtained for this report?
This report is an analysis of Medicare Part B DMEPOS claims with allowed services for the HCPCS codes listed in Table 1 with dates of service from October 1, 2016 to September 30, 2017. This analysis was based on the latest version of claims available from the Integrated Data Repository (IDR), as of January 24, 2018. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).
How were providers selected to receive CBRs?
After analyzing all of the data for each individual referring provider, we chose those providers that were Significantly Higher than their peers in at least one of the three measures analyzed. Additionally, each of these providers met certain thresholds of allowed charges and beneficiary counts. For this CBR, recipients had at least $5,000 in allowed charges in referrals and referred at least 10 beneficiaries to receive these spinal orthoses. This allowed charges threshold is near the 90th percentile of all referring providers of these spinal orthoses, and were chosen to ensure that the providers had sufficient information to compare to the peer groups, and that they could benefit from the educational material supplied in the CBR letter.
How are the peers defined?
Each billing provider was identified by their National Provider Identifier (NPI). The peer groups that are used for comparison with individual providers were identified, as follows:
- State: All Medicare providers listed as referring provider on claims with allowed charges for the selected Spinal Orthoses HCPCS codes who are located in the individual provider’s state, as identified through the PECOS system.
- National: All Medicare providers listed as referring provider on claims with allowed charges for claims for the selected Spinal Orthoses codes.
What do the comparison outcomes mean?
The four possible outcomes for the comparisons between the provider and peer groups are:
- Significantly Higher - provider’s value is higher than the peer value and the statistical test used confirms significance
- Higher – provider’s value is higher than the peer value, but either the statistical test does not confirm significance or there is insufficient data for comparison
- Does Not Exceed - provider’s value is not higher than the peer value
- N/A (Not Applicable) - provider does not have sufficient data for comparison
What is shown in Table 1?
Table 1 lists the HCPCS Codes and Types used in this report. Also shown for your referrals are total allowed charges, allowed services, distinct visit count, and distinct beneficiary count. Please note that the totals may not be equal to the sum of the rows due to rounding. Also, the beneficiary counts are unduplicated counts for each row and the total. For example, a beneficiary receiving multiple services with different HCPCS codes within this time period would be counted in the beneficiary count in each applicable row; however, this beneficiary would be counted only once in the total row. To review an example of a mock provider’s report, follow the web link at CBR201802 Sample CBR.
What is shown in Table 2?
Table 2 is an example of the Percentage of Services Defined as Custom-Fitted analysis. To illustrate this, refer to Table 2 of the mock provider’s CBR at the following link: CBR201802 Sample CBR. In this example, 38 percent of this provider’s referrals received custom-fitted orthoses. The state’s percentage is 14 percent, and the national percentage is 17 percent. This provider’s percentage is Significantly Higher than the state and national peer groups according to the results of the chi-square statistical test used in the analysis of this data. To view the results for all states and the nation, select the following link: CBR201802 Statistical Debriefing.
What is shown in Table 3?
Table 3 is an example of the Percentage of Allowed Services Submitted without a Visit to the Referring Provider within 90 Days of the DMEPOS Service Date analysis. The service date is defined as the date that the spinal orthosis order was filled by the DMEPOS supplier. To illustrate this, refer to Table 3 of the mock provider’s CBR at the following link: CBR201802 Sample CBR. In this example, 5 percent of this provider’s referrals had not visited the referring provider in the previous 90 days. The state’s percentage is 53 percent, and the national percentage is 51 percent. This provider’s percentage Does Not Exceed the state and national peer groups according to the results of the comparison in the analysis of this data. To view the results for all states and the nation, select the following link: CBR201802 Statistical Debriefing.
How was it determined if there was a visit to the referring provider within 90 days?
For each DMEPOS claim for the spinal orthoses HCPCS codes used in this report, the referring provider’s Part B claims were searched for the 90 days prior to the service date of the DMEPOS claim. The service date is defined as the date that the spinal orthosis order was filled by the DMEPOS supplier. Any visit by the beneficiary to the referring provider during this time period is considered a matching visit.
What is shown in Table 4?
Table 4 is an example of the analysis of the Average Allowed Charges per Beneficiary for the One-Year Period. To illustrate this, refer to Table 4 of the mock provider’s CBR at the following link: CBR201802 Sample CBR. In this example, this provider’s referrals resulted in average charges of $1,074.35. The state’s average is $924.00 and the national average $1,043.58. This provider’s average is Significantly Higher than the state and national peer groups according to the results of the t-test used in the analysis of this data. To view the results for all states and the nation, select the following link: CBR201802 Statistical Debriefing.