CMS announces first codes up for PA process

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Wednesday, December 21, 2016

WASHINGTON – CMS has announced the first two codes that will require prior authorization as a condition of payment.

In a final rule published in the Federal Register on Dec. 21, the agency says it will apply the PA process for two Group 3 power wheelchair codes, K0856 and K0861, in two phases on March 20, 2017, and July 17, 2017.

In phase one, CMS will limit the PA requirement to one state in each of the four DME MAC jurisdictions. The states are Illinois, Missouri, New York and West Virginia.

“Initially limiting the program to one state in each of the DME MAC geographic jurisdictions allows us to test the national claims processing system and the local DME MAC processes,” it states.

In phase two, it will expand the program to the remaining states.

CMS cleared the way to require PA as a condition of payment for certain DME in February 2016. The agency released a “master list” of 135 products for which it may apply the process, including CPAP devices, semi-electric hospitals, manual wheelchairs and oxygen concentrators.

As part of the process, prior to furnishing the item to the beneficiary and prior to submitting the claim for processing, a requester must submit a PA request the 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 supper-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.

K0856 is a power wheelchair, Group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds. K0861 is a power wheelchair, Group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.

Comments

Will CMS shorten it's medical review timeframe? (Say, instead of typically 30 business days, it can be 10?)