Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program includes 16 product categories. The product categories and their corresponding lead item Healthcare Common Procedure Coding System (HCPCS) codes are listed in the table below. Each product category that offers a CMS advisory article also includes a link to the article.
Within each of these product categories, a single lead item has been identified. Suppliers will submit one bid for the HCPCS code representing the lead item in the product category. Bids for the lead item will be used to calculate the single payment amounts for all of the items within that product category. For more information regarding the lead item, please refer to the Lead Item Pricing fact sheet. Files containing Round 2021 lead item and non-lead item HCPCS codes, as well as the Lead Item Pricing fact sheet, are available below. For HCPCS coding guidance and product descriptions, please visit the Medicare Pricing, Data Analysis, and Coding (PDAC) website.
* The law requires that OTS orthotics or braces be included in the DMEPOS competitive bidding program, specifically "orthotics which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual." Medicare Regulations define "minimal self-adjustment" as "an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and does not require the services of a certified orthotist or an individual who has specialized training." In cases where a beneficiary is not physically able to adjust the brace, the adjustment may be performed by the caretaker for the beneficiary or the supplier of the brace. The adjustment has to be one that a beneficiary, in general, could make themselves, following education and training on the proper use of the device, but the individual beneficiary does not always have to make the adjustment in order for the brace to be classified as OTS. When the beneficiary has a medical need for a brace that requires more than minimal self-adjustment and the brace has to be trimmed, bent, molded, assembled, or customized by an individual with expertise, the brace is not an OTS brace. The same back or knee brace may have separate codes in the event that the beneficiary needs the brace to be custom fitted. Payment for custom fitting is included in the separate code for the custom fitted brace. Please contact the Pricing, Data, Analysis, and Coding (PDAC) contractor with any questions regarding product classification or to submit a request for reconsideration.