Beginning in March 2017, CMS is phasing in new Medicare prior authorization (PA) requirements for two types of power wheelchairs under a policy adopted in a final rule issued late in 2015. As previously reported, CMS finalized regulations to require Medicare PA for certain durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) items that the agency characterizes as “frequently subject to unnecessary utilization.” CMS issued a “Master List” of equipment that could potentially be subject to this requirement, but the agency did not announce the specific selected items.
In a notice to be published December 22, 2016, CMS has announced the first two codes that will be subject to the new PA requirement:
- K0856 HCPCS: Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.
- K0861 HCPCS: Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.
CMS is phasing in implementation “because new complex claims processing systems changes are required for implementation.” In phase one, which is effective March 20, 2017, CMS is requiring prior authorization in one state in each of the four DME Medicare Administrative Contractors (MAC) geographic jurisdictions, as follows: Illinois, Missouri, New York, and West Virginia. In phase two, which begins July 17, 2017, CMS will expand the program to the remaining states. Note that this program does not create new clinical documentation requirements for the selected DMEPOS items. Instead, the same information necessary now to support Medicare payment for the item will be submitted to the MAC, but it will have to be submitted before the item can be furnished to the beneficiary and before the claim can be submitted for payment.