Find Out Which 4 Codes Are Off the DMEPOS 2018 Prior Authorization Master List

DMEPOS had a 44 percent improper payment rate according to CERT’s 2017 Medicare FFS report. That’s high. Really high. So anyone submitting claims that fall under DMEPOS needs to be up on all the rules. One important area to watch is Medicare’s Master List of which codes require prior authorization. The recent annual update posted in the Federal Register makes this a good time to get to know the Master List.

Know What’s New in the Latest Version

The 2018 update doesn’t add any codes to the Master List, and in fact deletes four HCPCS codes, meaning those codes no longer require prior authorization based on Master List criteria. The four codes deleted from the list are:

  • E0260 (Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress)
  • E0601 (Continuous positive airway pressure (CPAP) device)
  • E1390 (Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate)
  • K0004 (High strength, lightweight wheelchair).

What Does It Take to Get on the Master List?

The full name of the Master List is this mouthful: Final Master List of DMEPOS Items Subject to Frequent Unnecessary Utilization for Prior Authorization.

In short, codes go on the list requiring prior authorization if they have a high fraud or misuse rate.

Here are the specific criteria for getting on the list:

  • The item is on the DMEPOS fee schedule.
  • The item has an average purchase fee of $1,018 or more, or an average monthly rental fee schedule of $102 or more. Those are the “payment threshold” numbers for 2018. Prices are adjusted annually for inflation based on the original numbers of $1,000 and $100 in 2015.
  • The item meets either of these two criteria:
    • A GAO or OIG national report published in 2007 or later identifies the item as having a high rate of fraud or unnecessary utilization
    • A CERT FFS Improper Payment Rate Report DME Report’s Service Specific Overpayment Rate Appendix from 2011 or later lists the item.

According to the Federal Register posting, the four HCPCS codes removed from the Master List for 2018 no longer have a DMEPOS Fee Schedule price of $1,018 or greater or an average monthly rental fee schedule of $102 or greater. They don’t meet the payment threshold, so they’re off the list.

What About You?

Do you submit DMEPOS claims? What areas do you find the toughest to deal with?

 

 

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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