As of August 12, 2024, significant updates will take effect regarding the prior authorization and face-to-face encounter requirements for orthoses, impacting both providers and patients. In a recent move, the Centers for Medicare & Medicaid Services (CMS) has added six new HCPCS codes to the Required Prior Authorization List and eight codes to the Required Face-to-Face Encounter and Written Order Prior To Delivery (WOPD) List. This article, brought to you by Manager of Clinical Education Sam Brouillette, CP, CFo, will provide an overview of these changes.
Staying informed is essential to maintaining high-quality patient care and avoiding treatment delays. Let’s examine the specifics of these new requirements and what they mean for your clinic.
Orthoses Prior Authorization Changes Effective August 12, 2024
CMS added six orthoses HCPCS codes to the Required Prior Authorization List. DME MACS will begin accepting prior authorization requests for these codes on July 29, 2024:
- L0631
- L0637
- L0639
- L1843
- L1845
- L1951
SPS Clinical Note:
- All six orthoses codes being added to the Required Prior Authorization List, effective August 12, 2024, are currently on the Required Face-to-Face Encounter and WOPD List.
Orthoses Required Face-to-Face Encounter and Written Order Prior To Delivery (WOPD) Changes Effective August 12, 2024
CMS added eight orthoses HCPCS codes to the Required Face-to-Face Encounter and WOPD List:
- L0635
- L0636
- L0638
- L0639
- L0640
- L0651
- L1845
- L1852
SPS Clinical Note:
- L1845 and L0639 are also being added to the Required Prior Authorization List, effective August 12, 2024.
- L0635, L0636, L0638, L0640, L0651, and L1852 are NOT currently on the Required Prior Authorization List (as of 7/12/2024).
Prior authorization decisions for orthoses codes will remain valid for 60 calendar days following the affirmed review decision. Otherwise, the supplier must send a new request. If the two-day expedited review would delay care and risk the health or life of the beneficiary, CMS has suspended prior authorization requirements for orthoses HCPCS codes. Bill these claims using the ST modifier. The ST modifier is subject to prepayment review.
For more information, see the CMS Prior Authorization Process for Certain DMEPOS FAQs and Prior Authorization Process for DMEPOS Operational Guide.
References and Additional Resources