The following only applies if your physician or PT/OT practice is providing off-the-shelf back or knee braces.
Original Medicare patients who live in or travel to a competitive bidding area (CBA) and are prescribed off-the-shelf (OTS) back braces or OTS knee braces must use a competitive bidding contract supplier unless an exception applies. There are two exceptions for:
- Physicians and other treating practitioners (physician assistants, nurse practitioners, and clinical nurse specialists); and
- Physical therapists and occupational therapists
From January 1, 2021, thru December 31, 2023, the DME competitive bidding process will only be in effect for OTS back and knee braces, so this guidance only applies to these items during this time.
- To be paid for OTS back braces as a non-contract supplier, physicians and other treating practitioners should use the modifier KV and physical therapists and occupational therapists should use the modifier J5 in combination with the following HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650 and L0651.
- To be paid for OTS knee braces as a non-contract supplier, physicians and other treating practitioners should use the modifier KV and physical therapists and occupational therapists should use the modifier J5 in combination with the following HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852.
- On the claim billed to the DME MAC, the OTS back brace or OTS knee brace line item must have the same date of service as the professional service office visit or physical or occupational therapy service billed to the Part A/Part B MAC.
- Physicians and other treating practitioners and physical therapists and occupational therapists are advised to submit the office visit or therapy claim and the OTS back brace or OTS knee brace claim on the same day to ensure timely and accurate claims processing.
The KV and J5 modifiers are only required if you are in a CBA. CBAs are defined by ZIP codes. To determine if your ZIP code is in a CBA, enter it in the “FIND A CBA” tool on the tool bar at the top of the page at http://www.dmecompetitivebid.com. The “FIND A CBA” will also indicate the specific round that applies to a ZIP Code.
More information can be found at MLN Publication.
