PFA Works with National Supplier Clearinghouse and Centers for Medicare and Medicaid Services on Par
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PFA Works with National Supplier Clearinghouse and Centers for Medicare and Medicaid Services on Partial Solution to Change Request 3959

The Pedorthic Footwear Association (PFA) has contacted its network of allies in Congress and has worked with the National Supplier Clearinghouse (NSC) and the Centers for Medicare and Medicaid Services (CMS) on a partial solution to the problems caused by Change Request 3959 (CR 3959).

The Situation:

As you know, CR 3959, implemented as of October 1 and effective as of October 3, 2005, puts new edits in the DMERC claims processing system that will look for Specialty Codes 51, 52, 53, 55, 56, 57 (including pedorthists), 65, 67 and all Physician Specialty Codes listed in the Medicare Claims Processing Manual, Chapter 26, Section 10.8.2, in order to ensure that only those who specify P&O on their Enrollment Application Forms (Form CMS-855S) are reimbursed for P&O supplies.  This impacts only certified/licensed pedorthists in the states of Alabama, Florida, Illinois, New Jersey, Ohio, Oklahoma, Rhode Island, Texas, or Washington.

Impact on C. Peds./L. Peds. and what has been done:

Certified/Licensed Pedorthists in the states that have pedorthic licensure (Ohio, Oklahoma, Florida and Illinois) need to contact the National Supplier Clearinghouse IMMEDIATELY at (866) 238-9652 to determine which Specialty Code NSC has on file for you.  If it is a Specialty Code OTHER THAN 57, you need to inform NSC that you should be under code 57.  Then, you will need to send NSC a copy of your state license that allows you to practice pedorthics.  Once NSC has received a copy of your state pedorthic license, you will be assigned to the correct Specialty Code.

Certified pedorthists in the remaining five states (AL, NJ, RI, TX and WA) that have O & P licensure but NOT pedorthic licensure will remain unable to bill Medicare for certain orthotic devices as well as the L5000 and L5999 as listed in Transmittal 656 (go to for the complete list of codes that you will not be able to use. Please note that this entire Change Request DOES NOT IMPACT YOUR ABILITY TO BILL MEDICARE FOR A AND K CODES RELATED TO THE THERAPEUTIC SHOES FOR PERSONS WITH DIABETES BENEFIT, NOR DOES THIS CHANGE REQUEST IMPACT C. PEDS. IN ANY OTHER STATE.

The Future:

NSC and CMS have informed PFA during this process that it is aware of the overall problems caused by this CR. CMS will be examining changes to the CMS Form 855S (enrollment and change request form) to include a check box for pedorthists to make this entire Specialty Code updating process easier.

CMS is transferring its responsibility for qualified provider regulations for suppliers of O & P Medicare benefits to the states, and this is reflected in CR 3959.  It is now more important than ever for C. Peds. in at least the five states currently impacted by this CR to work with their state legislatures to enact pedorthic licensure, following the model legislation developed by PFA and the Board for Certification in Pedorthics (BCP) as soon as possible.  Once pedorthic licensure is on the books in these five states, C. Peds./L. Peds. in these five states will be able to enroll for Specialty Code 57 and bill Medicare for those certain orthotic codes and the L5000 and L5999. It is also imperative for BCP to take its self-proclaimed role as the lead on advancing state licensure across the country in general, and in these five states specifically.

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