On April 18, 2019 CMS announced that they are updating the Required Prior Authorization List of DMEPOS items that require prior authorization as a condition of payment to include seven additional power mobility devices and five pressure reducing support surfaces.
The following seven HCPCS codes for PMDs are being added to the Required Prior Authorization List:
K0857 - (Power wheelchair, group 3 standard, single power option, captains 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, captains 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)
These seven HCPCS codes will be including in the prior authorization program beginning July 22, 2019.
The following five HCPCS codes for Support Surfaces are also being added to the Required Prior Authorization List:
E0193 - (Powered Air Flotation Bed (Low Air Loss Therapy) )
E0277 - (Powered pressure-reducing air mattress)
E0371 - (Nonpowered advance pressure reducing overlay for mattress length and width)
E0372 - (Powered air overlay for mattress, standard mattress length and width)
E0373 - (Nonpowered advanced pressure reducing mattress)
Implementation for the seven support surface codes will be done in two phases. This phased-in approach will allow CMS to identify and resolve any unforeseen issues by using a smaller claim volume in phase one before nationwide implementation occurs in phase two.
In phase one of implementation, which begins on July 22, 2019, CMS will limit the prior authorization requirement to one state in each of the four DME Medicare Administrative Contractors (MAC) geographic jurisdictions, as follows: California, Indiana, New Jersey, and North Carolina.
In phase two, which begins October 22, 2019, CMS will expand the program to the remaining states.
The CMS’ Comprehensive Error Rate Testing (CERT) program continues to estimate high rates of improper payments for support surface codes. Since 2015, the estimated improper payment rate for these codes is over 59 percent, with an estimated improper payment rate of 75.2 percent, or over $18 million in projected improper payments for fiscal year 2018. Adding these five HCPCS codes for Support Surfaces to the Prior Authorization program will help CMS further program integrity goals of reducing fraud, waste, and abuse, while protecting access to care.
Prior to furnishing the item to the beneficiary and prior to submitting the claim for processing, a requester must submit a prior authorization request that includes evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. Such evidence must include the order, relevant information from the beneficiary’s medical record, and relevant supplier-produced documentation. After receipt of all applicable required Medicare documentation, CMS or one of its review contractors will conduct a medical review and communicate a decision that provisionally affirms or non-affirms the request.
Click here to view the official CMS notice.