CMS recently announced its plan to add 12 new HCPCS codes to the national Prior Authorization (PA) Program Master List.
So, what does this mean for HME providers? There will be seven complex rehab technology (CRT) power mobility (PMD) codes and five support surfaces codes added.
This implementation is a two-step process:
- Items potentially subject to PA are added to the Master List by CMS and updated annually via publication in Federal Register. This includes items / services that are both high cost and high risk for improper payments.
- Once an item is on the Master List, CMS can place any of those items on the “Required Prior Authorization List” at any time.
Prior Authorization Code Updates
PMD Code Additions
On July 22, 2019, the following PMD codes will be added to the PA list.
|K0857||Power wheelchair, group 3 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds|
|K0858||Power wheelchair, group 3 heavy duty, single power option, sling / solid set / back, patient weight 301 to 450 pounds|
|K0859||Power wheelchair, group 3 heavy duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds|
|K0860||Power wheelchair, group 3 heavy duty, single power option, sling / solid seat / back, patient weight capacity 451 to 600 pounds|
|K0862||Power wheelchair, group 3 heavy duty, multiple power option, sling / solid seat / back, patient weight capacity 301 to 450 pounds|
|K0863||Power wheelchair, group 3 heavy duty, multiple power option, sling / solid seat / back, patient weight capacity 451 to 600 pounds|
|K0864||Power wheelchair, group 3 extra heavy duty, multiple power option, sling / solid seat / back, patient weight capacity 601 pounds or more|
Support Surface Additions
Support surfaces will be implemented in two phases.
- Phase one: PA takes effect in California, Indiana, New Jersey, and North Carolina only in July 2019.
- Phase two: 180 days from publishing, PA for support surfaces will be expanded nationally.
|E0193||Powered air flotation bed (low air loss therapy)|
|E0277||Powered pressure-reducing air mattress|
|E0371||Non-powered advance pressure reducing overlay for mattress length and width|
|E0372||Powered air overlay for mattress, standard mattress length and width|
|E0373||Non-powered advanced pressure reducing mattress|
HCPCS Code Additions
In a recent annual update, CMS updated the Master List to include four additional HCPCS codes.
|E1390||Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate|
|E0466||Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)|
|E0784||External Ambulatory infusion pump, insulin|
|L0650||Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame / panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf|
What is the Impact?
The Good – The PMD PA demonstration has helped CMS reduce improper payments and could provide audit relief and reduction in appeals because medical necessity would have been met for the items(s).
The Bad – In terms of oxygen, timing of the authorization process is a critical factor in determining which product categories should be considered. For example, most oxygen patients need their oxygen immediately upon discharge. An additional step in the process is not considering patients over paperwork.
Will the DME MACs have enough qualified clinicians to conduct accurate reviews within a timely manner?
The Ugly – Patients who require oxygen / vent may not receive their service the same day. Therefore, patients’ lives might be compromised.
Do you have questions about prior authorization? Prochant’s HME billing experts are here to help. Contact us to see if we can help your business navigate these changes.
This is a guest post by Sharon Briggman, Prochant’s Director of Training & Compliance.
Prochant is the nation’s leading HME billing and process outsourcing company. Our highly-skilled team helps providers become more profitable by outsourcing or enhancing front- and back-office processes. We rapidly implement changes and proactively monitor metrics to ensure client success. Headquartered in Charlotte, North Carolina, we work with top medical equipment providers and health systems.