CMS announces Oct. 1 start date for PMD demo expansion

Tuesday, July 29, 2014

WASHINGTON – CMS will expand its PMD demonstration to 12 additional states on Oct. 1, the agency announced in a final rule published this week.

CMS plans to require prior authorizations for PMDs in Pennsylvania, Ohio, Louisiana, Missouri, Washington, New Jersey, Maryland, Indiana, Kentucky, Georgia, Tennessee and Arizona—all of which have high expenditures and improper payments based on 2012 billing data, the agency states in the rule.

CMS kicked off the PMD demo in California, Florida, Illinois, Michigan, New York, North Carolina and Texas on Sept. 1, 2012. Based on preliminary data, PMD spending in these states has decreased, indicating that physician ordering and supplier billing practices have changed as a result of the demo, the agency states.

Together, the 19 states that will eventually be involved in the demo account for 71% of all expenditures for PMDs in 2012, CMS states.

CMS’s education efforts prior to the start date of the expansion will include website postings, tweets, webinars, in-state meetings and other educational sessions, according to the rule.

The expansion affects:

·      Group 1 power operated vehicles (K0800 through K0802 and K0812);

·      All standard power wheelchairs (K0813 through K0843);

·      All Group 2 complex power wheelchairs without power options (K0848 through K0855);

·      Pediatric power wheelchairs (K0890 and K0891); and

·      Miscellaneous power wheelchairs (K0898).

Under the demo, a physician, treating practitioner or supplier may submit the prior authorization request and all relevant documentation to support Medicare coverage of the PMD item, along with the written order for the covered item, to their DME Medicare Administrative Contractor (MAC).

After receipt of all relevant documentation, CMS or its agents will make every effort to conduct a complex medical review and postmark the notification of their decision within 10 business days.

If a subsequent request is submitted after a non-affirmative decision on a prior authorization request, CMS or its agents will make every effort to conduct a review and postmark the notification of decision within 20 business days.

In large part, stakeholders have supported the demo and have argued that, with a few tweaks, it should be implemented nationally.