DMEPOS Suppliers Beware: Pressure Reducing Support Surfaces Now Require Prior Authorization Nationwide

The Centers for Medicare & Medicaid Services (“CMS”) announced in April of this year that it is adding 12 new HCPCS codes to the Required Prior Authorization List of DMEPOS items that require prior authorization as a condition of payment. Prior authorization for Pressure Reducing Support Surfaces will be implemented nationwide in October.

CMS added five HCPCS codes for Pressure Reducing Support Surfaces to the Required Prior Authorization List which will be implemented in phases. They included:

  • Powered Air Flotation Bed (Low Air Loss Therapy) (E0193)
  • Powered pressure-reducing air mattress (E0277)
  • Nonpowered advance pressure reducing overlay for mattress length and width (E0371)
  • Powered air overlay for mattress, standard mattress length and width (E0372)
  • Nonpowered advanced pressure reducing mattress (E0373)

CMS will implement the prior authorization program for these five HCPCS codes for Support Surfaces in two phases. In phase one of implementation, which began on July 22, 2019, CMS limited the prior authorization requirement to one state in each of the four DME Medicare Administrative Contractors (MAC) geographic jurisdictions (California, Indiana, New Jersey, and North Carolina).

In phase two, which begins on October 21, 2019, the program will expand nationwide.

Additionally, during the first phase of the implementation, effective July 22, 2019, 7 HCPCS codes were also implemented for power mobility devices. They included:

  • Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds (K0857)
  • Power wheelchair, group 3 heavy duty, single power option, sling/solid set/back, patient weight 301 to 450 pounds (K0858)
  • Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds (K0859)
  • Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds (K0860)
  • Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0862)
  • Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds (K0863)
  • Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more (K0864)

The regulations now require that prior to furnishing the item to a Medicare beneficiary and prior to submitting a claim for payment, a requester must submit a prior authorization request that includes evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. Per regulations, 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.

If you have questions regarding the prior authorization requirement or have other health law related questions, please contact our office.