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CMS to Implement Prior Authorization for Lower Limb Prosthetics

Aug 26, 2020

Prior to the COVID-19 public health emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) stated that six lower limb prosthetic Healthcare Common Procedure Coding System (HCPCS) codes (L-5856, L-5857, L-5858, L-5973, L-5980, and L-5987) would be subject to prior authorization as a Medicare condition of payment in four states (Texas, Pennsylvania, Michigan, and California) beginning May 11, 2020. These states would serve as a pilot program testing the new prior authorization requirements, which would be implemented nationwide beginning October 8. In light of the pandemic, CMS paused this new program for lower limb prosthetics in March.

On July 1, CMS announced that it will resume this program and require prior authorization for the six codes with dates of service on or after September 1, 2020 in the same four states, CMS will then expand prior authorization nationwide beginning on December 1, 2020. This revised timeframe leaves only three months (instead of the original five) to incorporate lessons learned from the pilot into the nationwide rollout of the program.

In addition, on June 26, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis, and Coding Contractor (PDAC) published a joint announcement and a revised Lower Limb Prostheses Local Coverage Article announcing that claims will not be paid for these six prosthetic codes with dates of service on or after January 1, 2021, unless the specific prosthetic component has undergone PDAC code verification and approval to bill a specific L- Code has been published on the appropriate Product Classification List.

Some stakeholders in the orthotic and prosthetic industry have requested that CMS postpone the implementation of prior authorization for the six billing codes until January 1, 2021, which would coincide with the new coding verification requirement issued by the PDAC. These stakeholders have argued that further delay in this new prior authorization is justified because physicians will need to be education on the prior authorization process and will have to cooperate with prosthetists, therapists, and their patients before a patient can receive care that involves components described by any of these billing codes. However, as of this publication, CMS has not announced any intention to further delay the program.

Concerns about prior authorization during a pandemic are obvious. Physicians fighting COVID-19 on the front lines should not be required to be educated about new documentation requirements for Medicare beneficiaries with limb loss to gain access to appropriate prosthetic care. The risk is that providers will seek to avoid delays in obtaining physician documentation by shifting practice patterns away from the six lower limb codes, sending a false signal to CMS that these prosthetic components are not necessary for optimal prosthetic outcomes. Unless and until CMS revises the forthcoming prior authorization requirements, physiatrists should be aware that they will come into effect in the states listed above beginning September 1, with the national rollout following on December 1. For interested practitioners, the DME MAC for Jurisdiction D, Noridian Healthcare Solutions, will be holding a provider outreach and education webinar on the new requirements at noon CT on September 10, 2020. The webinar will include discussion of prior authorization request basics, documentation requirements, and comprehensive error rate testing (CERT). For more information and to register for the webinar, click here.