UPDATES:
On January 12, 2022 the Centers for Medicare and Medicaid Services (CMS ) added the following 5 O&P HCPCS codes to the list of codes that will require Medicare Prior Authorization:
- L0648 Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
- 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
- L1832 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
- L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
- L1851 Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf
Medicare prior authorization for these five codes will be implemented in three phases. Phase 1 includes New York, Illinois, Florida, and California and begins on April 13, 2022. Phase 2 adds Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington and begins on July 12, 2022. Phase 3 includes all remaining states and territories and begins on October 10, 2022.
On April 12, 2022, CMS released guidance regarding Prior Authorization for emergent need orthoses. The CMS guidance stated that if the two-day expedited review process would delay care and risk the health or life of the beneficiary, the Medicare prior authorization requirement will be suspended. Claims for emergent need orthoses that would otherwise require Medicare prior authorization must be submitted with a “ST” modifier. While the ST modifier will allow claims to be processed and paid, all claims submitted with the ST modifier will then be subject to pre-payment review.
Prior Authorization Timeline:
2020
March 5, 2020: CMS Conference Call on Prior Authorization
February 11, 2020: CMS Announces Medicare Prior Authorization for 6 Lower Limb Prosthetic Codes
2019
October 31, 2019 Update: CMS Expands the Master List of HCPCS Codes Prior Authorization
On October 31, 2019, the Centers for Medicare and Medicaid Services (CMS) released its annual final rule regarding changes to the 2020 Medicare payment rules for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). As part of this final rule there was an expansion of the CMS “master list” of HCPS codes subject to prior authorization. Previously, only 82 O&P HCPCS codes were potentially subject to Medicare prior authorization. The final rule reduced the financial threshold for inclusion on the master list from an average reimbursement of $1,000 to an average reimbursement of $500. This reduction in the reimbursement threshold expanded the list of eligible O&P codes to 226 codes. In addition, the final rule also exposes the 226 O&P codes to potential inclusion in Medicare requirements for face to face visits with prescribing practitioners and written orders prior to delivery, two requirements that were previously not applicable to O&P services.
View the final rule here. The list of 226 O&P codes begins on page 397.
2016
December 19, 2016 Update: Initial Implementation of Prior Authorization
On December 19, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the initial implementation of the Medicare prior authorization program that was authorized through the final rule published on December 30, 2015.
As expected, CMS has chosen a cautious approach in implementing its prior authorization program. The initial list of codes subject to prior authorization only contains 2 codes, both of which describe power wheelchairs. The two codes selected are:
-K0856–Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds; and
-K0861–Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.
In addition to limiting the number of codes initially subject to prior authorization, CMS has chosen to implement the prior authorization process in two phases. The first phase will be implemented on March 20, 2017 and will require prior authorization for the two codes above in one state within each DME MAC jurisdiction. The second phase will be implemented on July 17, 2017 and will expand the prior authorization program for the two codes above nationwide.
While the initial implementation of the Medicare prior authorization program does not include any lower limb prosthetic codes, the expectation remains that prior authorization for most lower limb prostheses will become reality at some point in the future.
AOPA will continue to monitor developments and communicate any new information to its members.
February 25, 2016 Update: What Happens Next and When on Prior Auth.
CMS has issued a final rule on Prior Auth and it includes O&P, so Prior Auth IS going to be part of your future! That said, what AOPA is hearing from CMS is a relatively cautious, long-view approach. We do NOT expect to see any list of P&O codes to be subject to Prior Auth. anytime soon-some folks looked for an O&P list to be published by the end of February—but a delay of 6 months to even 12 months seems much more likely. Why? Here are a few reasons: (1) CMS would like to see what happens on the pending LCD before it sets up a full mechanism for O&P Prior Auth. ; (2) CMS sees Prior Auth as something of a franchise—so far, as to power wheel chairs, it has gotten pretty good reviews, and they don’t want to risk moving too fast and getting slammed with bad results; (3) they heard the comments of AOPA, patients, Alliance and others at least as to: (a) not wanting to have Prior Auth result in patient delay in getting their prosthesis, and (b) trying to assure that the system is sufficiently well-designed that folks who receive a Prior Auth. approval are not then subject to any post-payment audits. When a CMS O&P list does come out, an incremental approach with regional trials is more likely than any immediate national policy.
So, AOPA members have the luxury of some extra time to plan and prepare. Obviously, while any situation with any government agency must be considered somewhat fluid as people and policies can change, AOPA’s assessment on timing is based on a solid sense of reliability of information we have received, and we are confident that it aligns with current CMS plans and timing. Take advantage of AOPA’s Prior Auth. education programs. Whenever Prior Auth. for O&P is implemented it will be all about having your documentation right!
2015: Final Rule for Prior Authorization is Released
On December 29th 2015, the Centers for Medicare and Medicaid Services (CMS) released the long anticipated final rule regarding Medicare prior authorization of certain DMEPOS, including most lower limb prostheses. The final rule, which was published in the December 30, 2015 Federal Register, will be implemented 60 days after it publication.
AOPA has reviewed the final rule, and offers the following preliminary thoughts and comments regarding the provisions of the final rule.
AOPA’s primary concern with prior authorization of prostheses is, and always has been, that it will critically delay timely access to the provision of prosthetic devices that are crucial to the rehabilitation needs of Medicare beneficiaries. In the final rule, CMS acknowledged that proper access to medically necessary care is of the utmost importance, but indicated that it will use sub-regulatory processes to determine appropriate timelines for making prior authorization decisions. These sub-regulatory processes are inherently arbitrary in that they do not allow for public input and or comment regarding their appropriateness. AOPA remains concerned that prior authorization of any kind will only serve to hinder the delivery of medically necessary prosthetic care within reasonable timeframes.
Another concern that AOPA expressed in its comments on the proposed rule that was not sufficiently addressed in the final rule is that prior authorization does not equate to a guarantee of claim payment nor does it eliminate the exposure of the claim to additional audits. While the final rule states that an affirmative prior authorization decision indicates that the required documentation for claim payment is present, it also reiterates that it is not an initial claim determination and the claim may ultimately be denied for technical reasons such as invalid proof of delivery documentation.
AOPA met with representatives from the Office of Management and Budget (OMB) in August while they were reviewing the proposed rule and registered concerns about the above issues.
The few seeming new wrinkles in the final rule is that implementation will not be immediate and universal, but there will be a Master List of 135 HCPCS codes eligible for inclusion in prior authorization. It appears there will a phase-in process, meaning not all 135 codes will be subject to prior authorization immediately. Rather, the final rule indicates that CMS will establish a subset of the master list that will determine which HCPCS codes require prior authorization as part of the initial implementation of the final rule. While the master list includes lower limb prosthetic HCPCS codes that meet or exceed the $1,000 threshold, it remains to be seen which codes will be included in the initial list of codes that will be subject to prior authorization.
While the current list does not include any orthotic codes, AOPA remains concerned that future updates to the master list may include orthotic codes that meet the criteria for inclusion in prior authorization.
At first glance, the final rule does not recognize two key facts from Medicare’s own data:
- There is not a problem of unnecessary utilization of lower limb prosthetics, and the -14% reduction in prosthetics payments over the 2010-13 period proves that;
- Today, Medicare prosthetic patients are 35% LESS LIKELY to receive an advanced tech prosthetic device than they were just 5 years ago (2005-2009).
In addition, the final rule acknowledges AOPA’s concern regarding the need for a more timely response to prior authorization requests but elects to define these timeframes through sub regulatory processes that do not allow for public comment or input.
While AOPA will review the final rule more closely in the coming days, After its preliminary review, AOPA believes that the final rule fails to address AOPA’s concerns regarding the implementation of a prior authorization program that:
- Does not appear to constitute a guarantee of payment; and
- Retains the payment threshold of $1,000 for inclusion in prior authorization
- Does not assure that providers would not be subject to post-payment/RAC audits on the very same issue of medical necessity; and
- Uses sub-regulatory processes to define appropriate timeframes for response to prior authorization requests; and
- Exceeds its authority to initiate a limited pilot on prior authorization, done only in selected areas (as was done with power mobility devices) to a national policy impacting all amputee beneficiaries nationwide.
AOPA will provide additional analysis of the final rule as it becomes available.
2014: Prior Authorization Proposed Rule Released
Although CMS may have thrown us a curve when they published their proposal to require 89 lower limb prosthetic codes be subject to prior authorization on May 28, 2014, it became clear that in its proposed form, the rule would do more harm than good.
AOPA’s Board authorized an educational campaign to inform members about how this rule could impact patients in delaying access to care and delayed provider reimbursements among other problems. AOPA held 2 free webinars for members to learn from AOPA Board members and staff about what Prior Authorization is and is not. AOPA submitted comments to CMS on behalf of members, and encouraged members to submit their individual comments or use the template and pre-written comments detailing the problems in the Prior Authorization proposal and what needed to be changed to make it workable for patients and the O&P community. 448 members commented using AOPA’s online portal on AOPAvotes.org.
AOPA also mailed all patient care member locations 10 postcards for distribution to amputee patients so they could register their concerns directly with CMS about how Prior Authorization will negatively impact patient care. 294 patient postcards were delivered to CMS by the July 28, 2014 deadline!
In total AOPA members and their patients submitted 742 comments, in addition to customized comments that members submitted directly to CMS. Read AOPA’s statement here.
RESOURCES:
Prior Authorization Background Video
AOPA is working closely and collaboratively with the DME MACs to ensure that the Medicare prior authorization process is equitable, efficient, and does not contribute to unnecessary delays in the delivery of clinically appropriate prosthetic care to Medicare beneficiaries. As part of this effort, AOPA has developed the AOPA Medicare Prior Authorization Tracking Tool (AMPATT). The AMPATT is an intuitive, easy to complete form that will allow you to not only track the status and progress of your respective prior authorization processes, but also share this information with AOPA so we can provide valuable feedback to the DME MACs. Download the AMPATT here.
Noridian’s Prior Authorization for Lower Limb Prosthetics reminders.
CGS’s Prior Authorization for Lower Limb Prosthetics reminders.