LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Corporate

Print | Bookmark | Email | Font Size: + |

SHARE EDUCATION FEEDBACK

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP)

Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) began January 1, 2021, and extends through December 31, 2023.

Off-the-Shelf (OTS) Back Braces and OTS Knee Braces are the only two product categories included in Round 2021. You may refer to the Competitive Bidding Implementation Contractor (CBIC) websiteExternal Website for additional information on Round 2021 of the DMEPOS CBP.

Product Category HCPCS Codes Round 2021
OTS Back Brace HCPCS L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650 and L0651.
OTS Knee Brace HCPCS L1812, L1830, L1833, L1836, L1850, L1851, and L1852.

Note: Some Competitive Bidding Areas (CBAs)External Website may only have one product category.

How to determine if the beneficiary lives in a CBA:

The beneficiary's permanent residence is the address on file with the Social Security Administration (SSA). It is the address to which the SSA mails checks and/or correspondence to the beneficiary.

  • Use the myCGS Web Portal: As part of your intake process, check beneficiary eligibility, including CBA Information, located under the "Beneficiary Information" menu.
  • Use the Find a CBAExternal Website tool on the CBIC website to determine whether a specific ZIP code is included in the DMEPOS CBP.

Traveling Beneficiaries – KT Modifier

There are three important CBP rules to note when a beneficiary needs an OTS back or knee brace while traveling:

  1. Medicare payment is always based on the beneficiary's permanent residence.
  2. Which supplier may furnish the OTS back or knee brace is determined based on where the beneficiary purchases the item.
  3. The supplier that provides the OTS back or knee brace to the Medicare beneficiary must accept assignment (i.e., accept Medicare payment as payment in full) unless the beneficiary's permanent residence is not in a CBA and the beneficiary travels to an area that is not a CBA.

Suppliers must affix the HCPCS modifier "KT" to claims for OTS back or knee braces that are furnished to beneficiaries who permanently reside in a CBA and need a competitively bid item when they travel outside of the CBA where they reside.

NOTE: Suppliers that are not contracted with Medicare to furnish OTS back or knee braces for the CBA and inappropriately use the KT modifier on a claim for a competitively bid item may be subject to penalties under the False Claims Act.

Please refer to the Traveling Beneficiary Fact SheetExternal PDF for additional information, including various examples and scenarios.

Suppliers Who Do Not Have a Competitive Bidding Contract

Claims submitted for OTS back braces and knee braces with dates of service on or after January 1, 2021, will be denied if the beneficiary resides in a CBA and you are not a contract supplier in the DMEPOS CBP for the area where the beneficiary resides. You may not bill these beneficiaries for an OTS back brace or knee brace unless an Advance Beneficiary Notice (ABN) is provided to the beneficiary prior to furnishing the brace or the claim includes the KT modifier and meets the traveling beneficiary requirements noted above.

If you fail to issue a properly executed ABN, you will be responsible for the cost of the item and/or service and may not bill or collect, or you must refund amounts collected from the beneficiary.

Medicare will not pay non-contract suppliers furnishing competitively bid DMEPOS items to beneficiaries with Original Medicare in a CBA, unless one of the following exceptions applies:

  • Physicians and Other Treating Practitioners—Physicians and other treating practitioners who are enrolled Medicare DMEPOS suppliers may furnish competitively bid OTS back and knee braces in a CBA to their own patients without submitting a bid and being selected as a contract supplier. See the Physicians and Other Treating Practitioners, Physical Therapists, and Occupational TherapistsExternal PDF fact sheet on the CMS website.
  • Hospitals—Hospitals may furnish competitively bid OTS back and knee braces in a CBA to their own patients without submitting a bid and being selected as a contract supplier. See theĀ  Hospitals That Are Not Contract SuppliersExternal PDF fact sheet on the CMS website.
  • Medicare Secondary Payer—A non-contract supplier that has a valid Provider Transaction Access Number (PTAN) may receive a Medicare secondary payment for a competitively bid OTS back or knee brace furnished to a beneficiary residing in a CBA if the beneficiary is required to use that supplier under his or her primary insurance policy. This policy does not supersede any Medicare secondary payer payment laws, regulations, or policies. Payment will be calculated in accordance with Medicare secondary payer requirements.
  • Repairs and Replacements—Medicare allows for the repair and replacement of parts needed for the repair of beneficiary-owned items by any Medicare-enrolled supplier. Labor to repair OTS back and knee braces is not subject to competitive bidding and will be paid according to Medicare's general payment rules. Beneficiary-owned competitively bid OTS back or knee braces that are replaced, rather than repaired, must be furnished by contract suppliers when beneficiaries obtain these items in a CBA. See the Repairs and Replacements of Off-the-Shelf Back and Knee BracesExternal PDF fact sheet on the CMS website.

Modifiers

KV – Used by physicians that can furnish certain items from their office

KT – Beneficiary resides in a CBA and travels outside that CBA and receives a competitive bid item

J4 – Used by hospital-based suppliers with no contract that are allowed to furnish certain items

J5 – Used by PT/OT that are allowed to furnish certain items

Questions about Competitive Bidding:

  • Beneficiaries should call 1-800-MEDICARE (1-800-633-4227) for assistance with questions about the competitive bidding program or claims.
  • Suppliers or referral agents who have questions about the competitive bidding program should contact the CBIC:
    • Customer service center: 877-577-5331 (9 a.m.–5:30 p.m. Prevailing Eastern Time, Monday–Friday)
    • Email, eCHAT, and mailing address information: CBIC Contact InformationExternal Website.
  • Claim Questions: Suppliers should call the DME MAC for the area where the beneficiary permanently resides for assistance with claims questions.

Resources:

CMS MLN CBP Fact Sheets

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved