WASHINGTON, DC – On January 13, 2022, CMS published the HCPCS codes that will be added to the list of products that require a face-to-face encounter and written order prior to delivery (WOPD) as well as the HCPCS codes added to the list of products that require prior authorization.  These changes will have a big impact on suppliers of off-the-shelf and prefabricated orthotics and even more so if the supplier provides such products using consignment closets.

The following HCPCS codes will require a face-to-face encounter and WOPD effective April 13:

E0748       Osteogenesis Stimulator, Electrical, Non-Invasive, Spinal Applications.

L0648       Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T–9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf.

L0650       Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T–9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf.

L1832       Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise.

L1833       Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf.

L1851       Knee Orthosis (KO), 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, Prefabricated, Off-The-Shelf.

L3960       Shoulder Elbow Wrist Hand Orthosis, Abduction Positioning, Airplane Design, Prefabricated, Includes Fitting And Adjustment

For items on the Face-to-Face Encounter and WOPD List, the completed Standard Written Order (SWO) must be communicated to the supplier prior to delivery.  CMS also reiterated that if the face-to-face encounter is a telehealth encounter, the requirements of 42 CFR 410.78 and 414.65 must be met for DMEPOS coverage purposes.  These are the sections that require interactive audio and video communication and that the patient be located at a qualified “originating site.” Some of these requirements have been waived for the duration of the Covid Public Health Emergency (PHE) period.

The HCPCS codes being added to the list of products requiring prior authorization are:

K0800       Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds.

K0801       Power Operated Vehicle, Group 1 Heavy Duty, Patient Weight Capacity, 301 To 450 Pounds

K0802       Power Operated Vehicle, Group 1 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds.

K0806       Power Operated Vehicle, Group 2 Standard, Patient Weight Capacity Up To And Including 300 Pounds.

K0807       Power Operated Vehicle, Group 2 Heavy Duty, Patient Weight Capacity 301 To 450 Pounds

K0808       Power Operated Vehicle, Group 2 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds.

L0648       Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T–9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf.

L0650       Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T–9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf.

L1832       Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise.

L1833       Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf.

L1851       Knee Orthosis (KO), 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, Prefabricated, Off-The-Shelf.

The prior authorization requirement for the power mobility device HCPCS codes is effective April 13, 2022.  The implementation of the prior authorization requirement for the orthotic products is being conducted in three phases.  CMS stated that this phased-in approach will allow it to identify and resolve any unforeseen issues by using a smaller claim volume in Phase 1 before implementing phases 2 and 3.  The states selected for each phase was based on the highest utilization rates in each DME MAC jurisdiction.  The implementation for prior authorization for the orthotic HCPCS codes added is as follows:

Phase 1 effective April 13, 2022        New York, Illinois, Florida, and California

Phase 2 effective July 12, 2022          Phase 1 states and Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington

Phase 3 effective October 10, 2022    Nationwide

Suppliers of the products included on these lists will have to revise their operations to comply with the face-to-face encounter and WOPD requirements and/or the prior authorization requirements.

Lisa K. Smith, JD, is an attorney with the Health Care Group at Brown & Fortunato, PC, a law firm with a national health care practice based in Texas. She represents pharmacies, home medical equipment companies, hospitals, and other health care providers throughout the United States. Ms. Smith earned her law degree from the University of Texas School of Law. She is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6370 or [email protected].

Denise M. Leard, JD, is an attorney with the Health Care Group of Brown & Fortunato, a law firm with a national health care practice based in Texas.  Mrs. Leard represents HME companies, pharmacies, and other health care providers throughout the United States.  Mrs. Leard has authored numerous articles and is a frequent lecturer throughout the country.  She is licensed in Idaho, Oklahoma, Oregon, Texas, and Washington and is Board Certified in Health Law by the Texas Board of Legal Specialization.  Mrs. Leard earned a B.A. from the University of Washington and received her law degree from the University of Oklahoma College of Law.  She can be reached at (806) 345-6318 or [email protected].

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AAHOMECARE’S EDUCATIONAL WEBINAR

Federal Law Governing Medicare Advantage Plans and Medicaid Managed Care Plans

Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato

Tuesday, January 25, 2022

1:30-2:30 p.m. CENTRAL TIME

Medicare Advantage Plans (“MAPs”) and Medicaid Managed Care Plans (“MMCPs”) have become an important part of the lives of DME suppliers. Approximately 70% of Medicaid patients are covered by MMCPs, while approximately 39% of Medicare beneficiaries are covered by MAPs. These percentages will continue to increase. Working with MAPs/MMCPs is frustrating for suppliers. MAPs/MMCPs are heavy handed on a number of fronts. And so DME suppliers quite naturally ask what the federal laws are that govern MAPs/MMCPs. On the one hand, federal laws governing MAPs/MMCPs are quite extensive. However, only a small portion of the federal laws pertain to the relationship between the MAPs/MMCPs and the providers/suppliers that serve the patients covered by the plans. Much of the law is aimed to (i) protect covered lives and (ii) set minimum requirements for coverage, networks, complex reimbursement mechanisms. This program will discuss the federal laws that govern MAPs and MMCPs. Equally as important, this law will discuss how these laws affect DME suppliers as they provide services to patients covered by MAPs and MMCPs.

Register for Federal Law Governing Medicare Advantage Plans and Medicaid Managed Care Plans on Tuesday, January 25, 2022, 1:30-2:30 p.m. CT, with Jeffrey S. Baird, Esq. of Brown & Fortunato.

Members:  $99
Non-Members:  $129

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2022 Look Ahead for DME Suppliers

Presented by: Andrea Stark, MiraVista, LLC and Jeffrey S. Baird, Esq., Brown & Fortunato and moderated by: Liz Beaulieu, HME News

Thursday, February 3, 2022

1:00 p.m. EST

12th Annual Look Ahead Webinar

Well … 2022 has started off as crazy as 2020 and 2021 started off. Hopefully (fingers crossed) the Omicron variant will be the last gasp of the pandemic and COVID will morph into an annual endemic (i.e., one that we can live with). What is obvious is that the DME industry has shown brightly throughout the pandemic. DME suppliers stepped up and did whatever was necessary to take care of their patients and keep them out of the hospitals. The demand for DME is only going to increase in 2022 and beyond. This is the 12th year that Andrea and Jeff have presented their “Look Ahead” webinar. This webinar will focus on the most important issues that DME suppliers will have to deal with over the next 12 months. The goal of this program will be to provide knowledge and helpful tools for suppliers to utilize as they face the upcoming challenges. The program will focus on the following “hot button” issues:

• Future expectations of the DMEPOS Competitive Bidding Program.
• A new era in oxygen billing (including updated coverage updates and CMN elimination).
• Anticipated audit developments.
• Obligations arising out of the COVID public health emergency.
• The DME supplier’s role in remote patient monitoring (“RPM”).
• The relaxed telehealth restrictions.

There will be a live Q & A session following Andrea’s and Jeff’s presentation.

Register for the event.