Comparative Billing Reports

CBR201805 Knee Orthoses Referring Providers FAQs

General
Clinical and Billing
Report Specifics
 
General
What is the purpose of a comparative billing report on knee orthoses?

CBR201805 was created to inform providers about their referring patterns on claims submitted for knee orthoses and to see how their referral patterns compare to their peers. The CBR team reviewed Fee-for-Service (FFS) Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims with dates of service from January 1, 2017, to December 31, 2017. For more general information about CBRs, please visit our website at the link titled, Comparative Billing Reports.

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Why was knee orthoses chosen to be a CBR?

Knee orthoses was selected as a CBR topic because an Office of Inspector General (OIG) report determined that improper payment rates are high for knee orthoses. According to the 2017 OIG Work Plan, “Since 2009, Medicare payments…have more than doubled and almost tripled for certain types of knee braces.” Details of this report can be viewed at the following web link: 2017 OIG Work Plan.

 

Does receiving a CBR mean that I am referring beneficiaries incorrectly?

Receiving a CBR is not necessarily indicative of incorrect referring; however, it does mean that your referral patterns are different from your peers. There can be many reasons your referral 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.

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Should referring providers be concerned about impending audits if they 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 this CBR is to inform providers about their referral patterns for knee orthoses; however, selected providers may be referred for additional review and education. Also, it may be beneficial for providers to conduct self-audits. Resources to help with setting up an audit process are available at the following link: Self-Audit Help.

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Clinical and Billing
What are the top OIG concerns about referring providers of knee orthoses?

A 2018 OIG announcement has outlined some of the issues they will be looking into regarding knee orthoses. The biggest concern is a lack of documentation to support medical necessity. The OIG will also evaluate if beneficiaries are getting orthoses without visiting their referring physicians within the 12 months prior to receiving orthoses. The announcement can be viewed at this link:  Questionable Billing for Off-the-Shelf Orthotic Devices.

 

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What Healthcare Common Procedure Coding System (HCPCS) codes did you analyze for this CBR?

This CBR examines claims for custom-fitted and prefabricated off-the-shelf knee orthoses. The table below lists the Healthcare Common Procedure Coding System (HCPCS) codes included in the analysis for this CBR and abbreviated descriptions for each code:
 

Custom-Fitted Knee Orthoses

Prefabricated Off-the-Shelf

Knee Orthoses

HCPCS Code

Description

HCPCS Code

Description

L1810

Knee orthosis, elastic with joints

L1812

Knee orthosis, elastic with joints

L1820

Knee orthosis, elastic with condylar pads and joints

L1830

Knee orthosis, immobilizer

L1831

Knee orthosis, locking knee

L1833

Knee orthosis, adjustable knee

L1832

Knee orthosis, adjustable knee

L1836

Knee orthosis, rigid without joints

L1834

Knee orthosis, without knee joint

L1848

Knee orthosis, double upright

L1840

Knee orthosis, de-rotation

L1850

Knee orthosis, Swedish

L1843

Knee orthosis, single upright

L1851

Knee orthosis, single upright

L1844

Knee orthosis, single upright

L1852

Knee orthosis, double upright

L1845

Knee orthosis, double upright

 

 

L1846

Knee orthosis, double upright

 

 

L1847

Knee orthosis, double upright

 

 

L1860

Knee orthosis, modification

 

 

 

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What medical conditions qualify patients for knee orthoses?

Conditions that may qualify patients for knee orthoses include knee flexion contracture, knee extension contracture, weakness or deformity of the knee, and recent injury and/or surgery. Please remember that Medicare will only cover services that are reasonable and medically necessary and that meet the criteria for coverage of knee orthoses. For more details, please see the following web link: LCD L33318.

 

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Where can I find the coverage information about knee orthoses for my state?

Please refer to LCD L33318 and LCA A52465 for guidelines on knee orthoses for all states.  For answers to specific questions about knee orthoses, please contact the Medicare Administrative Contractor (MAC) for your jurisdiction. To find coverage guidelines, payment rules, and contact information for your MAC, select the following links:

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When is a prefabricated orthosis considered to be custom-fitted?

According to LCA A52465,  “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 detailed information can be found at the following link: LCA A52465.

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What specialized training is required?

A provider must meet the federal and state licensure and regulatory requirements for specialized training. Per LCA A52465, “Specialized training is defined as training that provides the knowledge, skills, and experience in the fitting of orthoses comparable to that of a certified orthotist. Individuals with specialized training necessary to provide custom fitting services for patients with a medical need for orthotics include: a physician, a treating practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist), an occupational therapist, or physical therapist.” For more information, select this web link: LCA A52465.

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What does substantial modification mean?

Per LCA A52465, “Substantial modification is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable federal and state licensure and regulatory requirements.” For more information, please refer to LCA A52465.

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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.

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How often can an orthosis be replaced?

Medicare requires a new prescription if an orthosis is being replaced. According to LCA A52465, “Replacement during the reasonable useful lifetime is covered if the item is lost or irreparably damaged.” If the item is being replaced for other reasons, it may be denied. To view the chart for the reasonable useful lifetime of prefabricated knee orthoses, select the following web link: LCA A52465.

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Are repairs to orthoses covered under Medicare?

According to LCA A52465, repairs to an orthosis are covered if they are “necessary to make the orthosis functional. The reason for the repair must be documented in the supplier’s record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.” For guidelines on repair of orthoses, select the following web links: LCD L33318, LCA A52465.

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Report Specifics
What were the criteria for receiving CBR201805? 

Our analysis of claims found that more than 89,000 providers nationwide have referrals for the knee orthoses codes included in this study. This CBR was sent to about 2,500 of these referring providers. The criteria for receiving this CBR were as follows:

  • Provider was significantly higher than at least one of the peer groups on at least one of the measurements studied
  • Provider was near or above the 90th percentile in allowed charges ($3,500) for referrals
  • Provider had referrals for at least 10 beneficiaries

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How was the data obtained for this report?

This report is an analysis of referring providers on Medicare Part B DMEPOS claims with allowed services for the HCPCS codes listed in table 1 with dates of service from January 1, 2017 to December 31, 2017. This analysis was based on the latest version of claims available from the Integrated Data Repository (IDR), as of April 3, 2018. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).

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How are the peers defined?

Each referring 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 practicing in the provider’s state who referred beneficiaries for the knee orthoses included in this analysis.
  • National: All Medicare providers in the nation who referred beneficiaries for knee orthoses included in this analysis.

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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 the statistical test does not confirm significance
  • 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

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What is the meaning of Table 1?

Table 1 lists the HCPCS codes and abbreviated descriptions included in this report. The codes identified are from the HCPCS level II codes maintained and distributed by CMS. To review an example of a referring provider’s report, select the web link at CBR201805 Sample CBR.

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What does Table 2 show?

Table 2 is a data summary of the provider’s referrals for knee orthoses HCPCS codes covered in this CBR. This table lists the HCPCS codes, allowed charges, allowed services, and beneficiary count. To see a sample report, select this web link: CBR201805 Sample CBR.

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What’s the significance of Table 3? 

Table 3 is the results of the analysis of the percentage of beneficiaries receiving knee orthoses for both knees. An example of this table can be viewed in the sample CBR, CBR201805 Sample CBR. Based on the chi-square test used in this analysis, the mock percentage of 23 percent is higher than the nation’s 21 percent, but does not exceed the state’s 25 percent. To read more about the methodology used for this calculation, and to view the results of all states and the nation, select the following link: CBR201805 Statistical Debriefing.

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How should providers interpret Table 4?

Table 4 is the results of the analysis of the percentage of services defined as custom-fitted. An example of this table can be viewed in the sample CBR, CBR201805 Sample CBR. Based on the chi-square test used in this analysis, the mock percentage was 88 percent, which was significantly higher than the state’s 45 percent and the nation’s 35 percent. To read more about the methodology used for this calculation, and to view the results for each state and the nation, select the following link: CBR201805 Statistical Debriefing.

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What does the analysis mean in Table 5?  

Table 5 is the results of the analysis of the percentage of services without a visit to the referring provider. An example of this table can be viewed in the sample CBR, CBR201805 Sample CBR. Based on the chi-square test used in this analysis, the mock percentage of services without a visit to the referring provider was 13 percent. This does not exceed the state’s 38 percent or the nation’s 40 percent. To read more about the methodology used for this calculation, and to view the results for each state and the nation, select the following link: CBR201805 Statistical Debriefing.

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What is the meaning of Table 6?

Table 6 is the results of the analysis of the average allowed charges per beneficiary. An example of this table can be viewed in the sample CBR, CBR201805 Sample CBR. Based on the t-test used in this analysis, the mock provider’s average charges per beneficiary of $913.27 was significantly higher than the state’s average of $651.72 and the nation’s average of $627.12. To read more about the methodology used for this calculation, and to view the results for each state and the nation, select the following link: CBR201805 Statistical Debriefing.

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