Updated: Oct 17, 2021
We anticipate it will be the first of more to come. Effective October 01, 2021, and per recent publications from Medicare, CMS will be rolling out a new Code Edit system to weed out Suppliers billing for a Custom Fit Orthotic HCPCS without having the correct specialty allocation from the National Supplier Clearinghouse (NSC).
Currently, 17 states require specialty personnel to make or fit custom orthotics. CMS will be taking those 17 states and cross-referencing the list of HCPCS codes billed for Custom Fit Orthotics to validate the provider is currently staffed to properly bill that code. Below, I've listed the 17 states and the Specialty Codes that correspond to the relative service(s).
If a provider is currently set up as a typical 51 Supplier and wishes to bill custom fit orthotics, they will have to update this information via their provider portal access
The VMS shall systematically load the following specialties in the VMS subsystem All Pricing, Provider, and Procedure Lookup (APPL) as required specialties for all HCPCS in the attachment.
• 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 Note: VMS has hard-coded logic in place to accept the physician specialties.
The 17 States that Require a Specialty Provider for Custom Fittings
Alabama, Arkansas, Florida, Georgia, Illinois, Iowa, Kentucky, Mississippi, New Jersey, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, and Washington.
If you are concerned about your provider specialty registration and need to update the information, we've provided a link to the National Supplier Clearinghouse (NSC) where you can find instructions for form CMS-855S to submit a change to your information. In addition, you can check the status of that update via the NSC Application Status tool.
Pro Tip! - ensure your liability insurance and bond insurance are all up to date and not pending expiration prior to submitting your Specialty Code updates. Otherwise, it will be rejected by the NSC. Their system won't allow for any updates if that information is expired.