On February 11, 2020 CMS will publish updates to the Federal Register, inlcuding the addition of six new codes to the prior authorization list. The Prior Authorization List includes DMEPOS items that require prior authorization as a condition of payment. Previously added codes included power mobility device codes and pressure reducing support surfaces.
The following six HCPCS codes for LLPs are being added to the Required Prior Authorization List:
L5856 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type)
L5857 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type)
L5858 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type)
L5973 – (Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source)
L5980 – (All lower extremity prostheses, flex foot system)
L5987 – (All lower extremity prosthesis, shank foot system with vertical loading pylon)
Implementation for the six lower limb prosthetic codes will be done in two phases. This phased-in approach will allow CMS to identify and resolve any unforeseen issues by using a smaller claim volume in phase one before nationwide implementation occurs in phase two.
In phase one of implementation, which begins on May 11, 2020, CMS will limit the prior authorization requirement to one state in each of the four DME Medicare Administrative Contractors (MAC) geographic jurisdictions, as follows: California, Michigan, Pennsylvania, and Texas.
In phase two, which begins October 8,2020, CMS will expand the program to the remaining states in all four jurisdictions.
Prior to furnishing the item to the beneficiary and prior to submitting the claim for processing, a requester must submit a prior authorization request that includes evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. Such evidence must include the order, relevant information from the beneficiary’s medical record, and relevant supplier-produced documentation. After receipt of all applicable required Medicare documentation, CMS or one of its review contractors will conduct a medical review and communicate a decision that provisionally affirms or non-affirms the request.
The updated Required Prior Authorization list is available in the download section of the following CMS website. The CMS and DME MACs will provide additional communications in the near future.