Accessories remain gray area for prior authorization process

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Friday, March 17, 2017

WASHINGTON – CMS officials spent much of a Special Open Door Forum on March 16 discussing whether or not accessories will be covered under a new prior authorization process for two complex power wheelchair codes.

During a Power Point presentation during the forum, CMS officials said accessories are not included in the process because all codes subject to prior authorizations must be included on a previously released “master list” of codes. To be included on that list, a code must have a fee schedule purchase amount of $1,000 or more, or a rental amount of $100 or more, or be the subject of review by the Office of Inspector General or the General Accountability Office, or be included in a recent Medicare improper payment report.

Accessories for power wheelchairs do not meet these criteria, CMS officials said.

But if an accessory is essential to the functioning of the power wheelchair, like a sip-and-puff, it will be considered part of the base and included as part of the prior authorization, they said.

While providers who called into a subsequent Q&A session were happy to hear that, they encouraged CMS officials to develop a formal list of accessories that they consider essential to the functioning of the power wheelchair to help providers avoid any grey areas.

Other items discussed during the Q&A session:

ADMC vs. PA

Providers who called into the forum noted that they prefer the six months they have to deliver equipment from the face-to-face evaluation as part of the advance determination of Medicare coverage process, versus the 120 days for the prior authorization process. CMS officials said they are open to that and would look into incorporating that into future guidance for the prior authorization process.

Existing claims

CMS officials said they would pass through all existing claims that have been approved by the ADMC process. When a provider shared that a reviewer with Noridian told her that any claims submitted through the ADMC process before March 19, even those she hadn’t received a determination for, would stand, CMS officials told her to follow those instructions.

CMS officials noted that the provider feedback during the forum gave them information to think about and ideas for improving the process going forward.

CMS officials will hold the second in its series of Special Open Door Forums on the prior authorization process this Tuesday.

CMS contractors CGS and Noridian on March 6 began accepting prior authorization requests for K0856 and K0861 for dates of delivery on or after March 20. The first phase of the process applies to Illinois, West Virginia, Missouri and New York, with a national rollout slated for July 17.