Expansion of the CMS Master List and the Prior Authorization Program

Effective August 12, Medicare is expanding its list of Healthcare Common Procedure Coding System (HCPCS) codes for prior authorization, face-to-face (F2F) encounters, and Written Orders Prior to Delivery (WOPDs). It will be pertinent for suppliers to review best practices for successful prior authorization due to the newly added (and removed) prior authorization codes as well as the list of codes that require a F2F and WOPD. It is important to note that inclusion of an O&P HCPCS code on the CMS Master List does not mean that code requires either a F2F and WOPD or prior authorization but indicates CMS could select that code for such requirements in the future. The newly added O&P codes are L-0457, L-1681, L-2006, L-2280, L-3761, L-4000, L-5615, L-5926, L-5991, L-6026, and L-7366. At this point, suppliers’ current processes do not need to change with the addition of codes to the Master List. Eight O&P codes have been added to the list requiring F2F encounters and a WOPD: L-0635, L-0636, L-0638, L-0639, L-0640, L-0651, L-1845, and L-1852. This means that effective for dates of service on or after August 12, these items must have a WOPD, which is basically a Standard Written Order that has been received prior to delivery and is dated no more than six months after the date of the F2F. A F2F is also required for these codes, which is an in-person office visit with a treating practitioner (MD, DO, PA, NP, or CNS) that has documented (at a bare minimum) a medical condition for which the device is ordered (full medical necessity coverage may be documented by another practitioner (MD, DO, PA, NP, or CNS) involved in the patient’s care or in the form of an addendum, if appropriate). The expansion of the prior authorization program includes the addition of the following O&P HCPCS codes: L-0631, L-0637, L-0639, L-1843, L-1845, and L-1951. These additions will also be effective for dates of service on or after August 12. It is in the best interest of the supplier to obtain a prior authorization if the item may be delivered on or after the effective date or risk an automatic claim denial. Noridian and CGS will notify suppliers when they begin allowing early submission of prior authorizations for these codes. Lastly, although rare, CMS has decided to remove HCPCS code L-1833 from the Master List. This means that for dates of service on or after August 12, this code will no longer require prior authorization, a F2F, or a WOPD, although existing standard documentation and policy requirements will still apply. For this code, continue current documentation processes and submission of prior authorizations until the effective date. In preparation for this change, suppliers should review their internal processes to make necessary changes to accommodate the addition and removal of these codes. For those using electronic medical record software, alerts can be added for these codes to notify staff of the new requirements for prior authorization and/or F2F and WOPD to avoid oversight. To read the rule, 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 and Written Order Prior To Delivery List; and Updates to the Required Prior Authorization List” on the Federal Register. Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are partners at O&P Insight, a consulting and billing company specializing in the O&P industry. Sisson and Bertram have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can reach them at lesleigh@oandpinsight.com or curt@oandpinsight.com. Michelle Wullstein, CPCO, has been in the Medicare profession for over 18 years and has received AAPC Certification as a Certified Professional Compliance Officer and provides O&P-specific medical policy, billing, documentation, and HIPAA compliance support to internal teams and clients. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.

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