CMS Makes Changes to DMEPOS Prior Approval, Other Restriction Lists

Do you work with DMEPOS - durable medical equipment, prosthetics, orthotics, and supplies? The U.S. Centers for Medicare & Medicaid Services has some important news for you.

On Jan. 13, CMS issued multiple updates related to the Healthcare Common Procedure Coding System, or HCPCS, related to the master list of DMEPOS items that may require prior authorization, face-to-face encounters, or written orders, as well as lists of items that definitely require those measures. The announcement also includes items CMS has deleted from its master list.

It's a long list that isn't presented in a particularly easy-to-use format, but according to APTA Policy and Regulatory Affairs Senior Specialist Steve Postal, it should be required reading for any PT involved in DMEPOS.

"CMS updates these lists annually, but this particular revision includes a lot of items that could have a real impact on PTs," Postal said. "Providers need to familiarize themselves with the changes to avoid any surprise claim denials."

Five Lists, Three Major Areas

The changes published by CMS fit into one of three categories:

• A "master list" of DMEPOS items that "are frequently subject to unnecessary utilization" and could be subject to prior authorization, face-to-face encounters, or written orders.
• Two separate lists of DMEPOS items subject to required face-to-face encounters and written orders prior to delivery - one for power mobility devices statutorily required to meet this standard, and one for DMEPOS that, while not statutorily required to meet the requirements, have been added nonetheless.
• DMEPOS items that always require prior authorization (sometimes only applicable in certain geographic regions in which CMS has found a particular problem with unnecessary use).

With an additional list of items deleted from the master list because they no longer meet minimum cost standards, CMS has published a total of five lists.

What's on the Lists?

The entire list is too long to include here, but a wide range of items are covered, including dressings, pneumatic compressors, several types of neuromuscular stimulators, manual wheelchair accessories, power wheelchairs and parts, and multiple orthoses.

An April Start-Up - And a Phased-In Approach

The updates will be effective April 13. Prior authorization will be phased in: the state from each of the four durable medical equipment Medicare administrative contractor areas with the highest utilization rates (New York, Illinois, Florida, and California) will begin April 13, with the next three-highest utilization states from each MAC area (Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington) added beginning July 12. The system goes nationwide beginning Oct. 10.