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May 25, 2021 - Updated September 14, 2021

Additional Payment Edits for DMEPOS Suppliers of Custom Fabricated and Prefabricated (Custom Fitted) Orthotics – CR 12282 - Updated

Effective Date: October 1, 2021
Change Request (CR) Number: 12282

This article was updated September 16, 2021 to revise the link to CR 12282External Website. Transmittal 10896, dated July 21, 2021, is being rescinded and replaced by Transmittal 11002, dated, September 13, 2021 to make additional updates to the OR01 and OR02 HCPCS Codes Attachment.

This article was updated July 22, 2021 to revise the link to CR 12282 and update the list of states according to instructions in Transmittal 10896.

CMS issued CR 12282External Website to communicate the addition of HCPCS codes that require the use of a licensed/certified orthotist or prosthetist for furnishing custom fabricated and prefabricated (custom fitted) orthoses. This change will apply to dates of service on or after October 1, 2021.

Suppliers may need to complete Form CMS-855S for change of information and submit applicable licenses or certifications to the National Supplier Clearinghouse (NSC)External Website.

CMS regulations require Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers to operate their business and furnish Medicare-covered items in compliance with all applicable federal and state licensure and regulatory requirements. Claims for Items furnished by personnel who are not licensed/certified orthotists or prosthetists by the state in which they practice will be denied. The following states require a licensed/certified orthotist or prosthetist to furnish orthotics or prosthetics: Alabama, Arkansas, Connecticut, Florida, Georgia, Idaho, Illinois, Iowa, Kentucky, Maryland, Minnesota, Mississippi, Nevada, New Jersey, North Dakota, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, and Washington.

In these 21 states where a licensed/certified orthotist or prosthetist must provide prosthetics and orthotics, suppliers can only bill Medicare for prosthetics and certain custom-fabricated orthotics when physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel, and prosthetics personnel furnish them. The following specialties shall bill for Medicare services when state law permits such entity to furnish a prosthetic or orthotic item:

  • Medical Supply Company with Orthotics Personnel – Specialty Code 51
  • Medical Supply Company with Prosthetics Personnel – Specialty Code 52
  • Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53
  • Orthotics Personnel – Specialty Code 55
  • Prosthetics Personnel – Specialty Code 56
  • Orthotics Personnel, Prosthetics Personnel, and Pedorthists – Specialty Code 57
  • Physical Therapist – Specialty Code 65
  • Occupational Therapist – Specialty Code 67
  • Pedorthic Personnel – Specialty Code B2
  • Medical Supply Company with Pedorthic Personnel – Specialty Code B3
  • Ocularist – Specialty Code B5

Effective for dates of service on or after October 1, 2021, if a supplier is located in one of the applicable states and wishes to bill Medicare for the prosthetics and custom fabricated orthotics attached to this CRExternal Website, it must properly enroll with the National Supplier Clearinghouse (NSC)External Website to ensure the correct specialty code(s) is on file.

If a supplier should need to update its file with the correct specialty, the supplier must submit a “Change of Information” on Form CMS-855S to the NSCExternal Website along with all applicable licenses or certifications.

Review the entire CMS instruction at CR 12282: Additional Payment Edits for DMEPOS Suppliers of Custom Fabricated and Prefabricated (Custom Fitted) OrthoticsExternal Website.


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