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~o PALMETTO GBA"' A CELERIAN GROUP COMPANY
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CBR201803 Spinal Orthoses
Rendering Providers
May 2, 2018
3:00 P.M. ET
mailto:[email protected]
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CBR201803 Spinal Orthoses
Rendering Providers
May 2, 2018
3:00 P.M. ET
Level II HCPCS codes are maintained and distributed by the
Centers for Medicare & Medicaid Services (CMS).
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CBR materials are prepared as a service
to the public and are not intended to grant rights
or impose obligations. The information provided in
the CBR material is only intended to be a general
summary. The CBR project has made every
reasonable effort to ensure the accuracy of the
information and web links provided in the CBR
materials at the time of publication; however, the
information and links within the material may
change without further notice. It is the
responsibility of the provider to remain up-to-date
with program guidelines.
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CBR201803 4
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Webinar Questions
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Submit questions using the Q & A buttonthroughout the
webinar
Ask questions pertinent to webinar
Email: [email protected]
CBR201803 5
mailto:[email protected]
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Webinar Outline
1. Introduction
2. Coverage & Documentation Overview
3. Data Sources & Results
4. References & Resources
5. Survey
CBR201803 6
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Webinar Objective
Upon completion of this webinar, you should be able to:
Demonstrate a general understanding of CBR201803: Spinal
Orthoses Rendering Providers
Comprehend the results
Locate policy references and resources
CBR201803 7
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mp=m Billini: Rqort ,(CBR)-.ac,es are co~a-ed ibyM.edic.areRmB.
Durab1eMS>11EcalEqwpl!!l.!l!.1 Pro5th!!cics. O:rt:lu,lic:s
o:n.dS,q,;, s MEPOS) .m>a they ""'fumish~oo aphy-,icim's omer
orin.ddmtto aphy;idm~semCJ!S. I!l!l!flsth.i!r do
not~Medicm"sd-=fici1ioaof.a brirne are not cc\emi!. The l!!ll!Oics
re\i.e,.ed in mis repori in.cmde:
i?eroanlage of illowed :il!El'ffi defuted as ,cu;rnm-fitted
Pe:ro;,nrage of illowied :il!IVi= rubmitte~ v.mbom" vi..,it ,o tbe
refemng jlroi.iJfer mrhm 90
da'y; c: the MEWS smicl! dilte A~ge clwges per b:ne,ilc:i.!.rr
fur 11!.e one,-year period
The Office ofm,-pector ~Jal (OIG) i:ndudes onbose; in fue Work:
Pim, Ffarol y.,..,. Wl report ,am.,! campo,re; M~c,e:rp,ymmt; fur
braces to 11!.ose ofpri!l'ate im:-=oe rnmpanL, (noJt-Medicm
payer,).. The orGm11de chese c.olllparisons in an effim to.
:l!en.til) pocmtiailly v.S!Stafu! speoomg amt ro a.dj;u;i. ib.e fee
sclJ.edJil.e for 11U!.()5e, to be m11re in lin.e v,,nn ooa, Me
-care ~i1~!!13 . The, ;, u.rk PI.an al.so in.dlJdes m~ev.1'1!
medi.
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Webinar Materials
References and Resources
Webinar slides
Recording of webinar
Webinar Handout
Webinar Q&A
CBR201803 9
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Acronyms Code Description
ABN Advance Beneficiary Notice
CMN Certificate of Medical Necessity
DMEPOS Durable Medical Equipment Prosthetics, Orthotics and
Supplies
HCPCS Healthcare Common Procedure Coding System
IDR Integrated Data Repository
LCD Local Coverage Determination
LCA Local Coverage Article
NCD National Coverage Determination
OTS Off-the-Shelf
CBR201803 10
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Coverage & Documentation Overview
Level II HCPCS codes are maintained and distributed by the
Centers for Medicare & Medicaid Services (CMS).
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Topic Selection - OIG
Medicare Supplier Acquisition Costs for L0631 Back Orthoses:
2008-2011
Claims for L0631 back orthoses more than doubled
Medicare allowances increased from $36 million to more than $96
million
Medicare payment amounts were more than 4 times greater than
supplier acquisition costs
CBR201803 12
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Billing Patterns
Billing may differ for many reasons:
Physician sub-specialties
Geographic location
Under-served urban areas
Rural areas
Patient acuity
More severe illnesses
CBR201803 13
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Definition
Medicare defines braces as rigid or 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.
CBR201803 14
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HCPCS Codes
HCPCS Code Type
L0627 Custom-Fitted
L0631 Custom-Fitted
L0637 Custom-Fitted
L0642 Off-the-Shelf
L0648 Off-the-Shelf
L0650 Off-the-Shelf
CBR201803 15
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Off-the-Shelf Orthoses vs Custom-Fitted Orthoses
Off-the-Shelf Custom-Fitted
Requires minimal self-adjustment for fitting Requires
substantial modification
Prefabricated Prefabricated
May or may not be supplied as a kit May or may not be supplied
as a kit
Does not require expert fitting Requires expert fitting at
delivery Certified orthotist or someone with specialized
training
CBR201803 16
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Modifiers
Modifier Description
EY No physician or other licensed health care provider order for
this item or service
GA Waiver of liability statement issued as required by payer
policy, individual case
GZ Does not meet Medicares reasonable and necessary rules and no
ABN was signed
KX Coverage criteria has been met
LT Left side
RT Right side
CBR201803 17
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Repairs and Replacements
Repairs: Covered to make item serviceable Billing should include
HCPCS, purchase date, price, product name, model, justification of
repair
Physicians order or Certificate of Medical Necessity (CMN) is
not needed
Replacement: Refers to an identical or nearly identical item
Replacement due to loss or irreparable damage (such as fire/flood)
does not require physicians order
Need physicians order to replace item due to irreparable wear or
change in patients condition (based on reasonable useful
lifetime)
CBR201803 18
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Documentation
Documentation Requirements:
Medical necessity
Type of orthosis
Detailed written order (DWO)
Detailed description of modifications and fitting for custom
fitted
Proof of delivery (POD)
CBR201803 19
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Local Coverage Determination and Articles
Covers all DME Jurisdictions:
LCD: L33790
LCAs: A52500, A55426
CBR201803 20
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Data Sources & Results
Level II HCPCS codes are maintained and distributed by the
Centers for Medicare & Medicaid Services (CMS).
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Report Data
Medicare Part B Rendering Providers (Suppliers):
By National Provider Identifier (NPI)
Selected Spinal Orthoses HCPCS Codes L0627, L0631, L0637, L0642,
L0648, L0650
Extracted: January 24, 2018 from Integrated Data Repository
(IDR)
Dates of Service: October 1, 2016 September 30, 2017
CBR201803 22
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Summary of Findings
Dates of Service: Oct. 1, 2016 Sept 30, 2017
Over 6,000 Suppliers
337,000 Beneficiaries
$358 Million
CBR201803 23
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Metrics and National Statistics
Percentage of Allowed Services Defined as Custom-Fitted
Nation: 17%
Percentage of Allowed Services Submitted Without a Visit to the
Rendering Provider within 90 Days of the DMEPOS Service Date
Nation: 51%
Average Allowed Charges per Beneficiary for the One-Year
Period
Nation: $1,040.34
CBR201803 24
http:1,040.34
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Specialty Groups
DMEPOS Supplier Not Likely to Have Orthotist Training
DMEPOS Supplier Likely to Have Orthotist Training
Physician/Nonphysician Not Likely to Have Orthotist Training
Physician/Nonphysician Likely to Have Orthotist Training
CBR201803 25
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Peer Groups
DME MAC / Specialty Group Medicare DMEPOS suppliers in the
suppliers jurisdiction within the same specialty group
National Specialty Group All Medicare DEMPOS suppliers in the
nation within the same specialty group
Specialty Group Information
https://www.cbrinfo.net/cbr201803_sample_cbr.pdf
CBR201803 26
https://www.cbrinfo.net/cbr201803_sample_cbr.pdf
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Comparison Outcomes
There are four possible outcomes:
1. Significantly Higher
2. Higher
3. Does Not Exceed
4. N/A
CBR201803 27
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Who Received a CBR?
Significantly Higher Than Peers
$5,000 Allowed Charges
10 Beneficiaries
2,021 Suppliers Received CBR201803
CBR201803 28
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References & Resources
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Comparative Billing Reports Comparative Billing Reports (CBRs)
are ed ucational too ls administered by the Centers for Medicare
& Medicaid Servk: es (CMS). They are developed and disseminated
under contract by eGlobalTech, a womanowned Federal services firm
based in Arlington , VA_
The CBRs are disseminated to the prov ider community to provide
insight into bill ing trends ac ross regions and policy groups. AJB
MACs have been produc ing and d isseminating limited numbers of
CBRs to targeted providers for many years. CMS has now formalized
and expanded the program to a national level. T he program also inc
ludes a CBR Support Help Desk that providers can contact to ask
questions regard ing ttle CBRs. Following the release of each CBR,
eGT w ill hOld an educational teleconference or webinar to educate
providers on tne substance of tne CBR and to provide an opportunity
to r providers to asl< questions.
r.1ost Recent CBR
t 1AC Contact I nforrnat1on
Update Your Address
Feedback.
CBR Website
http://www.cbrinfo.net
About Us CBR Releases Education Recommended Links FAQs CBR
Support Contact Us
CBR201803 30
http:http://www.cbrinfo.net
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CBR201803 Web Page
http://www.cbrinfo.net/cbr201803
Webinar Sample CBR Statistical Debriefing Recommended Links
FAQs
CBR201803 31
http://www.cbrinfo.net/cbr201803
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Provider Self-audit
Providers and suppliers have an obligation to ensure claims are
submitted correctlyto Medicare
Self-audits allow providers and suppliers to identify coverage
and coding errors
Refer to the following CBR sections for assistance Documentation
and Billing References
CBR201803 32
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CBR Support Help Desk
MondayFriday: 9:00a.m. to 5:00p.m. ET
Toll Free 18007714430
Email: [email protected]
CBR201803 33
mailto:[email protected]
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Contacting MACs
Providers should contact the Medicare Administrative Contractor
(MAC) for assistance with:
Claim Information
Documentation Requirements
Billing and Coding
CBR201803 34
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PECOS and NPPES
Provider Enrollment, Chain, and Ownership System (PECOS) and
National Plan and Provider Enumeration System (NPPES)
Sources for contact information used for the CBR
Correct your mailing information in PECOS at
https://pecos.cms.hhs.gov/pecos/login.do
Correct your contact information in NPPES at
https://nppes.cms.hhs.gov/
CBR201803 35
http:https://nppes.cms.hhs.govhttps://pecos.cms.hhs.gov/pecos/login.do
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Questions & Answers
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We make every effort to address all questions submitted during
our webinars. However, we cannot provide responses related to
coding issues or to specific claims/scenarios. Since your Medicare
Administrative Contractor (MAC) makes the determination to pay or
deny a claim based on the CPT or HCPCS codes, medical documentation
and description of the circumstances, and we do not have access to
this documentation, we cannot respond to these types of questions.
Please contact your MAC with questions that we do not address or if
you identify any claims discrepancies while reviewing your CBR. The
contact information for your MAC is located at
http://go.cms.gov/IMap.
CBR201803 37
http://go.cms.gov/IMap
Stay Tuned for WebinarCBR201803 Spinal Orthoses Rendering
ProvidersDisclaimer 2AnyMeeting Browser SupportWebinar
QuestionsWebinar OutlineWebinar ObjectiveSample CBRWebinar
MaterialsAcronymsCoverage & Documentation Overview Topic
Selection - OIGBilling PatternsDefinitionHCPCS CodesOff-the-Shelf
Orthoses vs Custom-Fitted Orthoses ModifiersRepairs and
ReplacementsDocumentationLocal Coverage Determination and
ArticlesData Sources & ResultsReport DataSummary of
FindingsMetrics and National StatisticsSpecialty GroupsPeer
GroupsComparison OutcomesWho Received a CBR? References &
ResourcesCBR WebsiteCBR201803 Web PageProvider Self-auditCBR
Support Help DeskContacting MACsPECOS and NPPESQuestions &
AnswersDisclaimer 3
