CMS has recently announced its intent to add 12 new HCPCS codes to the national Prior Authorization (PA) Program Master List.
What does this mean for HME businesses?
There will be seven complex rehab technology (CRT) Power Mobility (PMD) codes and five support surfaces codes added.
The implementation of the prior authorization for DME is a two-step process:
On July 22, 2019, the following PMD codes will be added to the PA list.
|K0857||Power wheelchair, group 3 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds|
|K0858||Power wheelchair, group 3 heavy duty, single power option, sling/solid set/back, patient weight 301 to 450 pounds|
|K0859||Power wheelchair, group 3 heavy duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds|
|K0860||Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds|
|K0862||Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds|
|K0863||Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds|
|K0864||Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more|
Support surfaces will be implemented in two phases.
|E0193||Powered Air Flotation Bed (Low Air Loss Therapy)|
|E0277||Powered pressure-reducing air mattress|
|E0371||Non-powered advance pressure reducing overlay for mattress length and width|
|E0372||Powered air overlay for mattress, standard mattress length and width|
|E0373||Non-powered advanced pressure reducing mattress|
In a recent annual update, CMS updated the Master List to include four additional HCPCS codes.
|E1390||Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at
the prescribed flow rate
|E0466||Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)|
|E0784||External Ambulatory infusion pump, insulin|
|L0650||Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf|
The Good – The PMD PA Demonstration has helped CMS reduce improper payments and could possibly include audit relief and a reduction in appeals because medical necessity would have already been met for the items(s).
The Bad – In terms of oxygen, timing of the authorization process is a critical factor in determining which product categories should be considered. Most oxygen patients need their oxygen immediately upon discharge. An additional step in the process is not considering patients over paperwork.
Will the DME MACs have enough qualified clinicians to conduct accurate reviews within a timely manner?
The Ugly – Patients who require oxygen / vent may not receive their service the same day, therefore, compromising patients’ lives.
If your team has questions about prior authorizations, Prochant’s team is available to help. Contact us today to see if we can help your business navigate these changes.
This is a guest post by Sharon Briggman, Prochant’s Director of Training & Compliance.
Prochant helps HME providers become more profitable by combining superior billing and process outsourcing with highly-skilled specialists. We audit existing front and back-office processes, rapidly implement changes, and conduct proactive analytics to enable providers to consistently exceed industry benchmarks. Headquartered in Charlotte, North Carolina, our clients include leading medical equipment providers and health systems.