CMS to Require Prior Authorization for Some Group 3 PWC Codes

The Centers for Medicare & Medicaid Services (CMS) plans to implement a prior authorization policy for two Group 3 power wheelchair codes.

The two affected codes 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).

The new prior authorization requirement will impact Medicare claims beginning on March 20 in four states: Illinois, Missouri, New York and West Virginia. CMS intends to roll the policy out nationwide in July.

In explaining the prior authorization process on its Web site, CMS said the new requirement “will require the same information necessary to support Medicare payment today, just earlier in the process. It will not create new clinical documentation requirements. The prior authorization process assures that all relevant coverage, coding and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment.”

A Medicare prior authorization power mobility device demonstration project featuring power wheelchairs and scooters has been in place for years in 19 states, but that demonstration didn’t include K0856 or K0861 codes.

That demonstration has been largely lauded in the industry because providers can check a Medicare beneficiary’s eligibility for the prescribed power mobility device before delivering the vehicle.

CMS published a final rule in December 2015 announcing its intention to implement “a prior authorization process for certain DMEPOS items that are frequently subject to unnecessary utilization.” The final rule included a list of 135 DME products that the agency had declared “frequently subject to unnecessary utilization. CMS would then implement a prior authorization rule for DME chosen from the list.

CMS had scheduled a Jan. 26 Open Door Forum to discuss the roll-out of the new prior authorization process for the K0856 and K0861 codes, but later canceled it. At press time, the agency had not announced a new date or time for the call.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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