On May 13, 2024, CMS published updates to the Master List of items that require a face-to-face encounter and written order prior to delivery (WOPD). In addition, CMS updated the Required Prior Authorization List, to include nine additional codes that will require prior authorization and removed one code. Keep reading below to see which codes have been added, removed, and the timeline for implementation.
Additions to the Required Prior Authorization List
|
HCPCS |
Description |
|
E0747 |
Osteogenesis stimulator, electrical, non-invasive, other than spinal applications. |
|
E0748 |
Osteogenesis stimulator, electrical, non-invasive, spinal applications. |
|
E0760 |
Osteogenesis stimulator, low intensity ultrasound, non-invasive. |
|
L0631 |
Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. |
|
L0637 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. |
|
L0639 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. |
|
L1843 |
Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. |
|
L1845 |
Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. |
|
L1951 |
Ankle foot orthosis (AFO), spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment. |
HCPCS L1833 (Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf) was removed from the required prior authorization list.
Required Prior Authorization List Implementation
CMS will implement prior authorization in two phases beginning on August 12, 2024. Phase 1 will include one State per Durable Medical Equipment Medicare Administrative Contractor (DME MAC) jurisdiction. The States included in phase 1 are California, Florida, Ohio, and Pennsylvania. Phase 2 will include all remaining U.S. States and territories not included in phase 1 and will be effective on November 12, 2024.
In addition to the updates made to the required prior authorization list, the Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery (WOPD) also have several updates.
The Master List serves as a library of items, that have been identified as potential vulnerabilities to the Trust Fund based on criteria outlined in 42 CFR 414.234(b), from which items may be selected to be placed on either the Required Face-to-Face Encounter and Written Orders Prior to Delivery List (the “F2F/WOPD List”) and/or Required Prior Authorization List under the authority provided under sections 1834(a)(1)(E)(iv), 1834(a)(11)(B), and 1834(a)(15) of the Act. Only those items that are selected and announced via Federal Register notice are subject to such regulatory conditions of payment.
CMS added a total of 76 HCPCS codes to the Master List. Of these 76 HCPCS codes, 56 are added because these items meet the updated payment threshold and are listed in an OIG or GAO report of a national scope or a CERT Medicare Fee-for-Service Supplemental Improper Payment Data report, or both; and 20 are being added for aberrant billing patterns. A full list of the HCPCS codes that were added to the Master List can be viewed in the Federal Register here.
Three HCPCS codes were removed from the Master List, these are:
- A7025: High frequency chest wall oscillation system vest, replacement for use with patient owned equipment
- E0565: Compressor air power source
- L1833: Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
Prior to publication of this Federal Register notice, 63 items have been included on the F2F/WOPD List. This Federal Register notice is adding the following 13 additional HCPCS codes to the F2F/WOPD List:
Additions to the F2F/WOPD List—New Non-Statutorily Required Items
|
E0290 |
Hospital bed, fixed height, without side rails, with mattress |
|
E0301 |
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress |
|
E0304 |
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress |
|
E0760 |
Osteogenesis stimulator, low intensity ultrasound, non-invasive |
|
E0747 |
Osteogenesis stimulator, electrical, non-invasive, other than spinal applications |
|
L0635 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, 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, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment |
|
L0636 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated |
|
L0638 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated |
|
L0639 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
|
L0640 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated |
|
L0651 |
Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf |
|
L1845 |
Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
|
L1852 |
Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf |
For items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, a complete order is required prior to the item’s delivery. (For all other DMEPOS items, the order is required prior to claim submission.)
Face-to-Face Encounter requirements applicable to certain DMEPOS items:
For all items requiring a face-to-face encounter, a practitioner visit is required within six months preceding the order. Note: face-to-face encounters for PMDs were previously required within 45 days preceding the written order.
The encounter must be used to gather subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective, beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
If the encounter is performed via telehealth, the requirements for telehealth services and payment for telehealth services must be met.
A supplier must maintain the written order/prescription and the supporting documentation provided by the treating practitioner and make them available to CMS and its agents upon request.
For more information, please refer to the CMS website on Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Order Requirements.