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Practice Affairs → Payment

Updates to payment policies by federal and private payers, strategies for navigating known payment issues as well as resources for correct coding and billing for physical therapy services, orthoses and supplies can be found here.

Numerous commercial payers including United Healthcare, Aetna, and Anthem, have suspended the 2% payment sequestration in alignment with the CARES Act for the remainder of 2020. As it relates to commercial payers, providers should be aware of the following:

  • Providers contracted with Medicare Advantage (MA) plans tied to the amount the providers would be paid under various Medicare payment systems, and/or tied to a portion of the plan’s capitation payments, generally should receive a 2% payment increase from the plans.
  • Providers not contracted with an MA plan also should receive at least a 2% increase because they are supposed to be paid at least what the provider would have received under original Medicare.
  • Some commercial contracts use Medicare-based rates. If the commercial plans using Medicare-based rates are applying sequestration on commercial claims, they may ‘forget’ to turn off these edits. Contact these plans individually to make sure they stop applying the 2% reduction.


CMS announced on 6/24/2020 that the ABN form (Form CMS-R-131) has been updated and approved by the Office of Management and Budget. The old form dated 3/2020 expires 8/30/20. The new form must be used for dates of service beginning 8/31/2020 and will be renewed 6/30/2023. The updated ABN with instructions will be found here: Updated ABN.

6/25/20 CMS announced new flexibilities for clinicians participating in the Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) in 2020. Clinicians significantly impacted by the PHE may submit an Extreme & Uncontrollable Circumstances Application which allows reweighting of some or all of the MIPS performance categories. Providers will be required to explain the practice impact due to the PHE. More information can be found on the QPP Covid-19 Response Page.

Paycheck Protection Plan Updates

Durable Medical Equipment

CMS’ DME MACs have collaborated to create a single National DME MAC Education webpage. The page will include self service tools &resources, Medicare updates, allow confirmation of beneficiary eligibility, allow providers to check claim status, same or similar information and more. CMS DME MAC Education Resource

Orthosis payment denial and recoupments

CMS DME MACs are enforcing a long-standing regulation relating to the payment for custom, off-the-shelf adjustable and off-the-shelf orthoses. The Reasonable Useful Lifetime Standard (RUL) was established in 1990 and applied to orthoses and prostheses in 1992. The RUL states “The reasonable useful lifetime of an item of durable medical equipment shall be 5 years unless the Secretary (of Health and Human Services) has established an alternative reasonable lifetime for such item”. Alternative RUL’s have been established but not for upper extremity orthoses and supports. In January of 2019, the DME MACs began enforcing this rule, denying or recouping payment as far back as 3 years for orthoses and supports determined to be “duplicate” or “same or similar” to those dispensed to a given beneficiary within a 5-year period.

A coalition of stakeholders, organized and led by APTA in conjunction with the Hand Academy, collected data and met with CMS representatives in Baltimore to present information surrounding the issue. Following the meeting, CMS representatives made 2 requests: 1). Stakeholders should meet with the DME MACs and 2). Stakeholders should provide detail regarding the specific HCPCS codes affected and provide background information on the establishment of the standard and information supporting a more appropriate standard for upper extremity orthoses. On behalf of the group, Kara Gainer, APTA’s Director of Regulatory Affairs, requested the meeting with the DME MACs, which was declined due to the RUL being a national and not a regional standard. The second criterion was met in February and a document was submitted to CMS for review which included a recommendation to establish a 3-year RUL for UE orthoses. This recommendation was based on extensive research and discussion with thermoplastic manufacturers and experienced hand therapists. APTA followed up in April to determine if additional information was needed. We are anticipating the release of the proposed interim physicians’ fee schedule rule for 2021 (July 2020) which may contain information regarding CMS’ response.

In the meantime, the following information may be helpful to providers of orthoses and supports for Medicare beneficiaries:

Resources for Providers

  1. Prior to supplying or fabricating an orthosis for Medicare or Medicare Advantage (MA) beneficiaries, check to determine if they have had the same equipment issued in the past 5 years. You can find this information through the IVR for Noridian MAC’s (JA, JD) or through the provider portals for all jurisdictions (JB, JC will not provide this information via the IVR.). Many beneficiaries travel or may have multiple homes, so it may be necessary to check multiple MACs.

  2. If the same orthosis or support has been supplied in the past 5 years, the provider has the following options:

    1. If there has been a change in the patient’s condition justifying the orthosis, the item should be supplied and the KX modifier appended to the claim line along with the RT or LT modifier. The referring provider’s medical records demonstrating the change in medical condition should be submitted with the claim.
    2. If the patient requests a replacement due to wear, a replacement is not covered and this will be an out of pocket expense. An ABN should be issued and signed by the beneficiary. The item on the claim line should include a GA modifier to signify a signed ABN is on file along with the RT or LT modifier so the denial indicates “patient responsibility” instead of “provider responsibility.”
    3. The beneficiary requests a replacement due to loss, theft, or irreparable damage not related to daily wear, the RA, KX and RT or LT modifiers should be added to the claim line along with a narrative description of the circumstances, submission of a police report or insurance claim confirming the loss or theft. While not a CMS requirement, submitting a photograph of the damage is recommended.

    Noridian provides an “on demand” webinar with additional information regarding claim submission: Orthotics Same or Similar Webinar.

    A list of other webinars covering orthosis payment and coding can be found here: CMS Orthosis on demand webinars.

Private Payers

Coding and Billing