Medicare claims for ultralightweight manual wheelchairs (HCPCS code K0005) with dates of service of Oct. 28 or later will need to go through the prior authorization process.
The July 30 edition of the Federal Register listed eight HCPCS codes, including K0005, that will be required to use prior authorization. The other codes are E0194 (air fluidized bed); L1833 (knee orthosis, adjustable knee joints); L0456 (thoracic-lumbar-sacral orthosis, flexible, prefabricated item customized to fit a specific patient); L0457 (thoracic-lumbar-sacral orthosis, flexible, prefabricated, off the shelf); L0486 (thoracic-lumbar-sacral orthosis, triplanar control, includes carved plaster or CAD-CAM model, custom fabricated); L3761 (elbow orthosis); and L3916 (wrist hand orthosis).
The Centers for Medicare & Medicaid Services (CMS) tied the new prior authorization policies to its ongoing focus on reducing fraud.
“We believe prior authorization of these eight additional HCPCS codes will help further our program integrity goals of reducing fraud, waste and abuse, while also protecting access to care,” the Federal Register article said. “In addition, recent enforcement actions by the U.S. Department of Justice have continued to demonstrate broader program integrity risks, including fraudulent billing schemes involving medically unnecessary equipment, the submission of claims lacking documentation of medical necessity, and the use of telemarketing arrangements targeting Medicare beneficiaries.”
Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) codes previously selected for prior authorization won’t be impacted.
“The remaining 74 HCPCS codes currently subject to the DMEPOS prior authorization requirement will continue uninterrupted,” the article said.
