CMS expands prior authorization for DME

Prior authorization is the bane of many family physicians’ existence. Despite their pleas for relief, the Centers for Medicare & Medicaid Services (CMS) has announced its intent to expand prior authorization for two pieces of durable medical equipment (DME).

The items in question are both power wheelchairs represented by the following Healthcare Common Procedure Coding System codes:

• K0856: Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.
• K0861: Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.

Last December, CMS said it would begin requiring prior authorization for these items in Illinois, Missouri, New York, and West Virginia, beginning for items furnished on or after March 20. Now, CMS said it intends to expand that prior authorization requirement nationwide, beginning for items furnished on or after July 17.

Suppliers of these products will require prior authorization as a condition of payment, so if you prescribe or order a power wheelchair for a Medicare patient, do not be surprised if the supplier requests additional documentation to facilitate the prior authorization. Also, do not be surprised if it takes your patient longer to receive the equipment while the prior authorization process plays out.

For additional information on DME prior authorization under Medicare, you can visit the Prior Authorization Initiatives page on the CMS web site. Also, CMS is hosting a Special Open Door Forum (conference call) on the subject on July 6 at 2 p.m. (Eastern Time). To access the call, dial 1-800-837-1935 and mention conference ID # 37139406. CMS will post a transcript and audio recording of this Special Open Door Forum to the Special Open Door Forum website for downloading sometime after the call.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians