Additional HCPCS Codes Added to Prior Authorization List

WASHINGTON, (April 18, 2019)—The Centers for Medicare & Medicaid Services (CMS) has selected 12 additional items of Durable Medical Equipment (DME) to be subject to required prior authorization (CMS 6080-N2).

CMS is adding the following seven Healthcare Common Procedure Coding System (HCPCS) codes for power mobility devices (PMDs) to the Required Prior Authorization List: K0857, K0858, K0859, K0860, K0862, K0863 and KO864. Prior authorization for these PMDs will be implemented nationwide, beginning July 22, 2019.

CMS is adding the following five HCPCS codes for pressure reducing support surfaces (PRSS) to the Required Prior Authorization List: E0193, E0277, E0371, E0372 and E0373. Prior authorization for PRSSs will be implemented in two phases. Phase one will begin July 22, 2019. CMS will limit prior authorization to one state in each of the four DME MAC jurisdictions as follows: California, Indiana, New Jersey and North Carolina. Phase two will begin Oct. 21, 2019 and expands prior authorization of these codes to the remaining states and territories. 

All HCPCS codes previously added to the Required Prior Authorization List will continue to be subject to the requirements of prior authorization. 

In addition, CMS has provided the annual update to the master list of DMEPOS items that the Secretary determined, on the basis of prior payment experience, are frequently subject to unnecessary utilization (CMS 6078-N2). As noted in CMS 6050-F, the agency adjusts the payment threshold each year for inflation. This update adds the following four HCPCS codes to the master list because they meet the updated payment threshold and are listed in a CERT DME and/or DMEPOS Service Specific Report: E1390, E0466, E0784 and L0650.

Oxygen Added to Master List

CMS implements prior authorization (PA) for DME through a two-step process. First, CMS includes on the Master List all items that are potentially subject to prior authorization, and this Master List is updated annually via publication in the Federal Register. Once an item is on the Master List, CMS can place any of those items on the “Required Prior Authorization List,” at any time, via publication in the Federal Register. 

In the annual update to the PA Master List, CMS announced the addition of four oxygen codes. 

• E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
• E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
• E0784 External Ambulatory infusion pump, insulin
• L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Items on the PA Master List are eligible to be included in the national PA program and are based on several criteria established by CMS in the 2015 final rule. 

The complete Required Prior Authorization List and the updated master list are found here. CMS will continue to post additional information, including an updated Operational Guide and Frequently Asked Questions on the announcement page.

Visit cms.gov for more information.