Skip Prior Authorization for These 4 HCPCS Codes
Effective April 30, four HCPCS Level II codes for certain durable medical equipment (DME) will no longer require prior authorization. If your medical office or facility sells or rents DME, it’s time to update your list.
Master List Agenda
The Centers for Medicare & Medicaid Services (CMS) published a final rule in the March 30 Federal Register to notify the public of updates made to the Master List of Items Frequently Subject to Unnecessary Utilization, which is used to identify durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) subject to prior authorization as a condition of payment.
Master List Criteria
Established in 2015, the Master List includes items that meet the following criteria:
- Appear on the DMEPOS fee schedule list
- Have an average purchase fee of $1,000 or more or an average monthly rental fee schedule of $100 or more (both amounts, referred to as “payment thresholds,” are adjusted annually for inflation)
- The payment threshold, for example, is $1,018 for an average purchase fee and $102 for the average monthly rental fee.
- Meet either of the following criteria:
- Identified as having a high rate of fraud or unnecessary utilization
- Listed in the Comprehensive Error Rate Testing (CERT) program’s annual Medicare Fee-For-Service Improper Payment Rate Report DME and/or DMEPOS Service Specific Report(s)
Master List Update
The Master List is self-updating annually to account for coding and regulatory changes, among other things. The following four HCPCS Level II codes are being removed from the Master List because they no longer exceed the payment threshold:
|E0260||Hospital bed semi-electric (head and foot adjustment) with any type side rails with mattress|
|E0601||Continuous airway pressure (CPAP) device|
|K0004||High-strength, lightweight wheelchair|
Click on the link below for the full updated Master List.
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