PMD Prior Authorization
On Sept. 1, Medicare implemented a power mobility device (PMD) prior authorization demonstration project in California, Florida, Illinois, Michigan, New York, North Carolina and Texas. It applies to physician orders written on or after that date for most PMD codes (K0800-K0855, K0890-K0891 and K0898) with the exception of Group 3 complex rehab power wheelchairs with power options (K0856-K0864). CMS made some last-minute changes to the PMD Demonstration Operational Guide on August 28 that incorporates more of what stakeholders have asked for. Per the changes, CMS will permit physicians’ use of templates to facilitate medical record keeping, the ability for them to add or clarify information post examination, the treatment of accessories and the process to follow for beneficiary upgrades.
PMD providers have been advocating for a system that reflects the structure of those already in place within nearly all state Medicaid and private insurance plans. The industry supports a timely and efficient process because it provides a level of assurance that, once approved, the reimbursement will not be subject to recoupment years later for insufficient documentation. Having more certainty is a step in the right direction, especially with the ongoing barrage of industry audits. While some may approach this change with caution, successful providers will capitalize on the opportunities it provides.
Tips to Manage the Process—As with any change, a transition period exists to make the system operate smoothly. Reviewing the medical record and interpreting the coverage criteria will be key to the process. Providers who have not already incorporated this practice may submit the seven-element order, face-to-face examination report, any additional medical records or relevant information and the detailed product description to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for a prior authorization decision. The DME MAC will review the documentation, determine if the requirements have been met, and render a decision postmarked within 10 business days. With an affirmative decision providers can be more confident that they will be able to keep their money once the claim is processed.