The Centers for Medicare & Medicaid Services (CMS) updated the Federal Register with the list of Healthcare Common Procedure Coding System (HCPCS) orthoses codes that will require prior authorization beginning April 13.
The codes added to the list are:
- L-0651
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall
- L-1844
Knee orthosis, 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, custom fabricated
- L-1846
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
- L-1852
Knee orthosis, double 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
- L-1932
Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment
CMS also added 18 HCPCS codes as eligible for inclusion, four of which are orthoses codes, because they met “the criteria outlined previously to the Master List.
“Of these 18 HCPCS codes, eight are added because these items meet the updated payment threshold and are listed in an [Office of the Inspector General] or [Government Accountability Office] report of a national scope or a [Comprehensive Error Rate Testing] Medicare Fee-for-Service Supplemental Improper Payment Data report, or both; and ten are being added for aberrant billing patterns.
“The codes added due to aberrant billing patterns represents items for which data show suppliers submitted at least 1,000 claims and received at least $1 million in payments during the 12-month periods from July 2023 to June 2024. There was more than a 30 percent increase in payments for each item from the preceding 12-month period.”
O&P addition code that are eligible to be added to a required list are:
- L-1499
Spinal orthosis, not otherwise specified
- L-2999
Lower extremity orthoses, not otherwise specified
- L-5783
Addition to lower extremity, user adjustable, mechanical, residual limb volume management system
- L-5841
Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control.
There is no immediate direct impact to suppliers for items being added to the Master List.
To read the update, visit “Medicare Program; Updates to the Master List of Items Potentially Subject to Face to Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements; Updates to the Required Face-to-Face Encounter and Written Order Prior to Delivery List; and Updates to the Required Prior Authorization List” on the Federal Register.
