The O&P Alliance is examining a troubling issue that has recently developed from CMS contractor publications. First, some background. In 2014, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication indicating that a custom fabricated, externally powered, upper extremity assistive device fell within the DME benefit and should be paid under the capped-rental payment methodology. At that time, the DME MACs stated that claims for these types of devices should be submitted using the DME miscellaneous E code, E1399.
In May 2016, the Pricing and Data Administrative Contractor (PDAC) released a publication about the correct coding of powered exoskeleton devices that stated, “Although these products resemble ‘orthoses’, for Medicare HCPCS coding purposes brace-like products that exert a powered force across a joint are not coded as orthoses with HCPCS L codes but rather are coded using other HCPCS codes".
In the fall of 2018, CMS released the 2019 DMEPOS new Code Set. Included in the Code Set were two new codes, L8701 and L8702. These codes were created as a result of an application for new coding for two types of custom fabricated, upper extremity, externally powered orthoses. This action appeared to signal that CMS and the HCPCS Workgroup recognized that these powered custom fabricated devices were orthoses. However, on December 13, 2019 the DME MACs published a statement that said they have evaluated a specific custom fabricated upper extremity assistive device and determined that it falls within the DME benefit category.
This is concerning because this Medicare contractor is stating that a custom fabricated orthosis should be categorized as a DME item. Until recently the manufacturers of these powered orthoses have taken the main lead in interacting with CMS. The Alliance believes this is an important issue and plans on engaging CMS on this topic and will continue to provide information to educate CMS and its contractors that custom orthoses should not be classified as DME items.