Prior auths become law of land for two complex rehab codes

Process for K0856, K0861 began in four states in March
Friday, July 7, 2017

WASHINGTON – HME providers in all states must begin submitting prior authorization requests for two complex rehab codes starting July 17, CMS officials confirmed during a Special Open Door Forum on July 6.

Providers in Illinois, West Virginia, Missouri and New York have already had to submit PARs for K0856 and K0861 for dates of delivery on or after March 20 as part of the first phase of the process.

CMS officials told listeners the same rules apply in this second phase of the process, with one exception. They said claims for patients who have a representative payee now require PARs, unlike in the first phase.

During a question-and-answer session, CMS officials told listeners that they have instructed contractors to process any advance determination of Medicare coverage requests, or ADMC requests, through July 17.

CMS officials also told listeners during the Q&A that they do not expect the national roll out to affect the timeframes put in place during the first phase of the process. Those timeframes include reviewing initial requests and postmarking decision letters within 10 business days, and reviewing resubmitted requests and postmarking decision letters within 20 business days. A CMS official said the contractors are appropriately staffed and ready to handle the increase in volume.

This was the fourth forum that CMS has held on the prior authorization process for K0856 and K0861. Previous forums have largely focused on whether or not accessories are covered under the process.

CMS outlined its plans to require prior authorizations as a condition of payment for certain DME back in February 2016. The agency released a “master list” of 135 products for which it may apply the process, including CPAP devices, semi-electric hospital beds, manual wheelchairs and oxygen concentrators.

Then in a final rule published in the Federal Register on Dec. 21 of that year, CMS announced it had selected K0856 and K0861 as the first codes up for the process.

CMS also has a prior authorization process in place for standard power wheelchairs in 19 states, as part of a demonstration project.