The Centers for Medicare & Medicaid Services (CMS) released a multi-part announcement related to O&P billing and coding. The following topics were included in the publication:
- Prior authorization will be required for additional O&P-related Healthcare Common Procedure Coding System (HCPCS) codes.
- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items have been added to the master list that could be subject to a face-to-face encounter, written order prior to delivery, and prior authorization.
- One O&P item has been removed from the master list.
- HCPCS codes have been added that will require a face-to-face encounter and written order prior to delivery as a condition of payment.
Prior authorization
The codes that will require prior authorization are:
- L-0648 (Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf)
- L-0650 (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)
- L-1832 (Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise)
- L-1833 (Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf)
- L-1851 (Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf)
Prior authorization for the added codes will be implemented in three phases. Phase 1 includes New York, Illinois, Florida, and California and begins on April 13. Phase 2 adds Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington and begins on July 12. Phase 3 includes all remaining states and territories and begins on October 10.
Additions to the master list
The following DMEPOS codes potentially subject to a face-to-face encounter, written order prior to delivery, and prior authorization requirements were added to the master list:
- L-0830 (Halo Procedure, Cervical Halo Incorporated Into Milwaukee Type Orthosis)
- L-1005 (Tension Based Scoliosis Orthosis And Accessory Pads, Includes Fitting And Adjustment)
- L-1906 (Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Off-The-Shelf)
- L-2580 (Addition To Lower Extremity, Pelvic Control, Pelvic Sling)
- L-2624 (Addition To Lower Extremity, Pelvic Control, Hip Joint, Adjustable Flexion, Extension, Abduction Control, Each)
- L7368 (Lithium Ion Battery Charger, Replacement Only)
Removal from the master list
L-3761 (Elbow Orthosis (EO), With Adjustable Position Locking Joint(s), Prefabricated, Off-The-Shelf) was removed the master list.
Face-to-face encounters and written order requirements
The following HCPCS codes will require a face-to-face encounter and written order prior to delivery as a condition of payment for claims with a date of service on or after April 13:
- L-0648 (Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf)
- 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)
- L1832 (Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise)
- L1833 (Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf)
- L1851 (Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf)
- L3960 (Shoulder Elbow Wrist Hand Orthosis, Abduction Positioning, Airplane Design, Prefabricated, Includes Fitting And Adjustment)
The American Orthotic & Prosthetic Association (AOPA) pointed out that inclusion of an HCPCS code on the master list does not mean that it is automatically subject to face-to-face encounter, written order prior to delivery, and prior authorization requirements. Inclusion only allows CMS to select the code for one or all these requirements in the future.
AOPA also released its initial thoughts regarding the potential impact of the changes prior to its in-depth analysis. :
- The added orthotic codes represent expansion of Medicare prior authorization beyond the six lower-limb prosthesis codes (L-5856, L-5857, L-5858, L-5973, L-5980, and L-5987) that have been subject to prior authorization since 2020.
- The codes that will require prior authorization have high utilization patterns and have been identified as having high potential for fraud and abuse.
- Four of the codes that are included in the expanded list of codes subject to prior authorization are included in the Medicare DMEPOS competitive bidding program.
- A concern about subjecting the five orthosis codes to Medicare prior authorization is that these orthoses often are needed immediately to stabilize an injured and unstable spine or knee. Requiring prior authorization may be challenging due to the acute nature of treatment with these orthoses.
To read the CMS announcement (CMS-6081-N), visit the Federal Register.
