CMS shifts mobility codes into nat’l prior authorization program

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Friday, June 8, 2018

WASHINGTON – CMS says a demonstration project requiring prior authorization requests for power mobility devices in 19 states will become permanent and will expand to all states.

CMS announced June 1 that it will transition nearly all of the codes included in the demo project, which was set to expire on Aug. 31, to its national prior authorization program on Sept. 1. Currently, the agency has two codes in the national program: K0856 and K0861, two complex rehab codes.

“This is something the industry has been strongly advocating for with CMS and Congress,” said Seth Johnson, vice president of government affairs for Pride Mobility Products.

Thirty-one codes—K0813 through K0855—will transition into the nationwide program; six codes—K0800, K0801, K0802, K0890, K0891, K0898, scooter and pediatric codes—will not, due to low utilization.

Stakeholders still await sub-regulatory guidance on the national program, but they expect CMS to hold itself to responding within 10 business days for initial requests and within 20 business days for resubmitted requests.

“There’s broad support, with one caveat,” said Don Clayback, executive director of NCART. “We think there’s a good system in place in the demo states, but for the additional states, we hope that Medicare contractors also have a system and adequate staff in place to meet timeframes.”

Two things that will go away along with the demo: an option for providers not to submit requests, in exchange for 25% less reimbursement; and an option for physicians and prescribing practitioners to bill for their paperwork using G1956.

“I don’t believe either is a big deal,” Johnson said.

One sticking point that stakeholders plan to address: Accessories still aren’t part of the program. They acknowledge that CMS’s hands were tied, because accessories aren’t part of a “master list” of products that meet certain criteria for being included in the program.

“It would be nice if they had expanded it a little more to include wheelchair options and accessories, but we know in talking to Medicare that they would need to make some changes in their authority to allow that,” Johnson said. “We’ll continue to work to find a way to expand it further.”

Still, stakeholders hold up the demo as a good example of what can happen when CMS and providers partner on an initiative.

“When the concept came up, there were distinct disconnects,” Clayback said. “Then we worked out the kinks over several months and, overall, now everyone’s happy with it. Providers get the assurance they’re going to get paid, and the payer gets to review claims before they’re paid.”