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Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP)

Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) began January 1, 2021, and extends through December 31, 2023.

All Medicare Round 2021 DMEPOS Competitive Bidding Program contracts for off-the-shelf back and knee braces expire on December 31, 2023. Starting January 1, 2024, there will be a temporary gap in the program. CMS plans to conduct bidding for the next round after the upcoming rulemaking process, including public notice and comment. See the Temporary Gap PeriodExternal PDF fact sheet for more information.

Off-the-Shelf (OTS) Back Braces and OTS Knee Braces are the only two product categories included in Round 2021. You may refer to the Competitive Bidding Implementation Contractor (CBIC) websiteExternal Website for additional information on Round 2021 of the DMEPOS CBP.

Product Category HCPCS Codes Round 2021
OTS Back Brace HCPCS L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650 and L0651.
OTS Knee Brace HCPCS L1812, L1830, L1833, L1836, L1850, L1851, and L1852.

Note: Some Competitive Bidding Areas (CBAs)External Website may only have one product category.

How to determine if the beneficiary lives in a CBA

The beneficiary's permanent residence is the address on file with the Social Security Administration (SSA). It is the address to which the SSA mails checks and/or correspondence to the beneficiary.

  • Use the myCGS Web Portal: As part of your intake process, check beneficiary eligibility, including CBA Information, located under the "Beneficiary Information" menu.
  • Use the Find a CBAExternal Website tool on the CBIC website to determine whether a specific ZIP code is included in the DMEPOS CBP.

Traveling Beneficiaries – KT Modifier

There are three important CBP rules to note when a beneficiary needs an OTS back or knee brace while traveling:

  • Medicare payment is always based on the beneficiary's permanent residence.
  • Which supplier may furnish the OTS back or knee brace is determined based on where the beneficiary purchases the item.
  • The supplier that provides the OTS back or knee brace to the Medicare beneficiary must accept assignment (i.e., accept Medicare payment as payment in full) unless the beneficiary's permanent residence is not in a CBA and the beneficiary travels to an area that is not a CBA.

Suppliers must affix the HCPCS modifier "KT" to claims for OTS back or knee braces furnished to beneficiaries who permanently reside in a CBA and need a competitively bid item when they travel outside of the CBA where they reside.

NOTE: Suppliers that are not contracted with Medicare to furnish OTS back or knee braces for the CBA and inappropriately use the KT modifier on a claim for a competitively bid item may be subject to penalties under the False Claims Act.

Please refer to the Traveling Beneficiary Fact SheetExternal PDF for additional information, including various examples and scenarios.

Suppliers Who Do Not Have a Competitive Bidding Contract

Claims for OTS back braces and knee braces with dates of service January 1, 2021 – December 31, 2023, will be denied if the beneficiary resides in a CBA and you are not a contract supplier in the DMEPOS CBP for the area where the beneficiary resides. During Round 2021, you may not bill these beneficiaries for an OTS back brace or knee brace unless you provide an Advance Beneficiary Notice (ABN) before furnishing the brace or the claim includes the KT modifier and meets the traveling beneficiary requirements described above.

If you fail to issue a properly executed ABN, you will be responsible for the cost of the item and/or service and may not bill or collect, or you must refund amounts collected from the beneficiary.

During Round 2021 of CBP, Medicare will not pay non-contract suppliers furnishing competitively bid DMEPOS items to beneficiaries with Original Medicare in a CBA, unless one of the following exceptions applies:

  • Physicians and Other Treating Practitioners—Physicians and other treating practitioners who are enrolled Medicare DMEPOS suppliers may furnish competitively bid OTS back and knee braces in a CBA to their own patients without submitting a bid and being selected as a contract supplier. See the Physicians and Other Treating Practitioners, Physical Therapists, and Occupational TherapistsExternal PDF fact sheet on the CMS website.
  • Hospitals—Hospitals may furnish competitively bid OTS back and knee braces in a CBA to their own patients without submitting a bid and being selected as a contract supplier. See the Hospitals That Are Not Contract SuppliersExternal PDF fact sheet on the CMS website.
  • Medicare Secondary Payer—A non-contract supplier that has a valid Provider Transaction Access Number (PTAN) may receive a Medicare secondary payment for a competitively bid OTS back or knee brace furnished to a beneficiary residing in a CBA if the beneficiary is required to use that supplier under his or her primary insurance policy. This policy does not supersede any Medicare secondary payer payment laws, regulations, or policies. Payment will be calculated in accordance with Medicare secondary payer requirements.
  • Repairs and Replacements—Medicare allows for the repair and replacement of parts needed for the repair of beneficiary-owned items by any Medicare-enrolled supplier. Labor to repair OTS back and knee braces is not subject to competitive bidding and will be paid according to Medicare's general payment rules. Beneficiary-owned competitively bid OTS back or knee braces that are replaced, rather than repaired, must be furnished by contract suppliers when beneficiaries obtain these items in a CBA. See the Repairs and Replacements of Off-the-Shelf Back and Knee BracesExternal PDF fact sheet on the CMS website.

Modifiers

KV – Used by physicians that can furnish certain items from their office

KT – Beneficiary resides in a CBA and travels outside that CBA and receives a competitive bid item

J4 – Used by hospital-based suppliers with no contract that are allowed to furnish certain items

J5 – Used by PT/OT that are allowed to furnish certain items

For dates of service on or after January 1, 2024, suppliers may no longer use the KV, J4, and J5 modifiers. Do not submit claims with these modifiers.

Questions about Competitive Bidding

  • Beneficiaries should call 1-800-MEDICARE (1-800-633-4227) for assistance with questions about the competitive bidding program or claims.
  • Suppliers or referral agents who have questions about the competitive bidding program should contact the CBIC:
    • Customer service center: 877-577-5331 (9 a.m.–5:30 p.m. Prevailing Eastern Time, Monday–Friday)
    • Email, eCHAT, and mailing address information: CBIC Contact InformationExternal Website.
  • Claim Questions: Suppliers should call the DME MAC for the area where the beneficiary permanently resides for assistance with claims questions.

Resources:

CMS MLN CBP Fact Sheets

Updated: 12.18.23

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