Medicare Program; Suspension of Required Prior Authorization for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items Under Certain Circumstances, 48609 [2022-17187]
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Federal Register / Vol. 87, No. 153 / Wednesday, August 10, 2022 / Rules and Regulations
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Parts 410 and 414
[CMS–6087–N]
Medicare Program; Suspension of
Required Prior Authorization for
Certain Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies
(DMEPOS) Items Under Certain
Circumstances
Centers for Medicare &
Medicaid Services (CMS), Department
of Health and Human Services, (HHS).
ACTION: Suspension of prior
authorization requirements for specified
orthoses prescribed and furnished
urgently or under special circumstances.
AGENCY:
This document announces the
suspension of prior authorization for
specified orthoses items on the Required
Prior Authorization List that require
prior authorization as a condition of
payment under certain circumstances
when reported with certain modifiers.
Items subject to face-to-face encounter
and written order prior to delivery
requirements are not impacted by this
document.
SUMMARY:
The suspension of the prior
authorization requirement discussed in
this document took effect on April 13,
2022, when CMS published an
announcement on its website.
FOR FURTHER INFORMATION CONTACT:
Emily Calvert, (410) 786–4277.
SUPPLEMENTARY INFORMATION:
DATES:
khammond on DSKJM1Z7X2PROD with RULES
I. Background
In the December 30, 2015, final rule
(80 FR 81674) titled, ‘‘Medicare
Program; Prior Authorization Process for
Certain Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies,’’
we implemented section 1834(a)(15) of
the Act by establishing an initial Master
List (called the Master List of Items
Frequently Subject to Unnecessary
Utilization) of certain DMEPOS that the
Secretary determined, on the basis of
prior payment experience, are
frequently subject to unnecessary
utilization and by establishing a prior
authorization process for these items.
In the November 8, 2019, Federal
Register (84 FR 60648), we published a
final rule titled, ‘‘Medicare Program;
End-Stage Renal Disease Prospective
Payment System, Payment for Renal
Dialysis Services Furnished to
Individuals with Acute Kidney Injury,
End-Stage Renal Disease Quality
VerDate Sep<11>2014
16:06 Aug 09, 2022
Jkt 256001
Incentive Program, Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
Amounts, DMEPOS Competitive
Bidding Program (CBP) Amendments,
Standard Elements for a DMEPOS
Order, and Master List of DMEPOS
Items Potentially Subject to a Face-toFace Encounter and Written Order Prior
to Delivery and/or Prior Authorization
Requirements.’’ Through this November
2019 final rule, we harmonized the lists
of DMEPOS items created by former
rules and established one ‘‘Master List
of DMEPOS Items Potentially Subject to
Face-To-Face Encounter and Written
Orders Prior to Delivery and/or Prior
Authorization Requirements’’ (the
‘‘Master List’’). The November 2019
final rule was effective January 1, 2020.
In January 13, 2022, Federal Register
(87 FR 2051), we published a document,
titled, ‘‘Medicare Program; Updates to
Lists Related to Durable Medical
Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS) Conditions of
Payment.’’ Through the January 2022
Federal Register document, we updated
the Master List and selected certain
lower limb orthoses, lumbar sacral
orthoses, and power mobility devices to
be subject to required prior
authorization. The January 2022 Federal
Register document was effective April
13, 2022.
II. Provisions of the Document
In accordance with 42 CFR 414.234(f),
CMS may suspend DMEPOS prior
authorization requirement generally or
for a particular item or items at any time
and without undertaking rulemaking.
Due to the need for certain patients to
receive an orthoses item that may
otherwise be subject to prior
authorization when the 2-day expedited
review would delay care and risk the
health or life of the beneficiary, we are
suspending prior authorization
requirements indefinitely, under these
limited circumstances:
• Claims for HCPCS codes L0648,
L0650, L1832, L1833, and L1851 that
are billed using modifier ST, indicating
that the item was furnished urgently.
• Claims for HCPCS codes L0648,
L0650, L1833, and L1851 billed with
modifiers KV, J5, or J4, by suppliers
furnishing these items under a
competitive bidding program exception
(as described in 42 CFR 414.404(b)), to
convey that the DMEPOS item is needed
immediately either because it is being
furnished by a physician or treating
practitioner during an office visit where
the physician or treating practitioner
determines that the brace is needed
immediately due to medical necessity or
because it is being furnished by an
PO 00000
Frm 00007
Fmt 4700
Sfmt 4700
48609
occupational therapist or physical
therapist who determines that the brace
needs to be furnished as part of a
therapy session(s).
Prior authorization will continue for
these orthoses items (HCPCS L0648,
L0650, L1832, L1833, and L1851) when
furnished under circumstances not
covered in this update, as well as all
other items on the Required Prior
Authorization List, available at https://
www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/
Medicare-FFS-Compliance-Programs/
DMEPOS/Downloads/DMEPOS_PA_
Required-Prior-Authorization-List.pdf.
The Administrator of the Centers for
Medicare & Medicaid Services (CMS),
Chiquita Brooks-LaSure, having
reviewed and approved this document,
authorizes Lynette Wilson, who is the
Federal Register Liaison, to
electronically sign this document for
purposes of publication in the Federal
Register.
Dated: August 5, 2022.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare
& Medicaid Services.
[FR Doc. 2022–17187 Filed 8–9–22; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Part 414
[CMS–5537–N]
Medicare Program; Alternative
Payment Model (APM) Incentive
Payment Advisory for Clinicians—
Request for Current Billing Information
for Qualifying APM Participants
Centers for Medicare &
Medicaid Services (CMS), Health and
Human Services (HHS).
AGENCY:
ACTION:
Payment advisory.
This advisory is to alert
certain clinicians who are Qualifying
APM participants (QPs) and eligible to
receive an Alternative Payment Model
(APM) Incentive Payment that CMS
does not have the current billing
information needed to disburse the
payment. This advisory provides
information to these clinicians on how
to update their billing information to
receive this payment.
SUMMARY:
E:\FR\FM\10AUR1.SGM
10AUR1
]]>Agencies
[Federal Register Volume 87, Number 153 (Wednesday, August 10, 2022)]
[Rules and Regulations]
[Page 48609]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-17187]
[[Page 48609]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 410 and 414
[CMS-6087-N]
Medicare Program; Suspension of Required Prior Authorization for
Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) Items Under Certain Circumstances
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health and Human Services, (HHS).
ACTION: Suspension of prior authorization requirements for specified
orthoses prescribed and furnished urgently or under special
circumstances.
-----------------------------------------------------------------------
SUMMARY: This document announces the suspension of prior authorization
for specified orthoses items on the Required Prior Authorization List
that require prior authorization as a condition of payment under
certain circumstances when reported with certain modifiers. Items
subject to face-to-face encounter and written order prior to delivery
requirements are not impacted by this document.
DATES: The suspension of the prior authorization requirement discussed
in this document took effect on April 13, 2022, when CMS published an
announcement on its website.
FOR FURTHER INFORMATION CONTACT: Emily Calvert, (410) 786-4277.
SUPPLEMENTARY INFORMATION:
I. Background
In the December 30, 2015, final rule (80 FR 81674) titled,
``Medicare Program; Prior Authorization Process for Certain Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies,'' we
implemented section 1834(a)(15) of the Act by establishing an initial
Master List (called the Master List of Items Frequently Subject to
Unnecessary Utilization) of certain DMEPOS that the Secretary
determined, on the basis of prior payment experience, are frequently
subject to unnecessary utilization and by establishing a prior
authorization process for these items.
In the November 8, 2019, Federal Register (84 FR 60648), we
published a final rule titled, ``Medicare Program; End-Stage Renal
Disease Prospective Payment System, Payment for Renal Dialysis Services
Furnished to Individuals with Acute Kidney Injury, End-Stage Renal
Disease Quality Incentive Program, Durable Medical Equipment,
Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts,
DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements
for a DMEPOS Order, and Master List of DMEPOS Items Potentially Subject
to a Face-to-Face Encounter and Written Order Prior to Delivery and/or
Prior Authorization Requirements.'' Through this November 2019 final
rule, we harmonized the lists of DMEPOS items created by former rules
and established one ``Master List of DMEPOS Items Potentially Subject
to Face-To-Face Encounter and Written Orders Prior to Delivery and/or
Prior Authorization Requirements'' (the ``Master List''). The November
2019 final rule was effective January 1, 2020.
In January 13, 2022, Federal Register (87 FR 2051), we published a
document, titled, ``Medicare Program; Updates to Lists Related to
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) Conditions of Payment.'' Through the January 2022 Federal
Register document, we updated the Master List and selected certain
lower limb orthoses, lumbar sacral orthoses, and power mobility devices
to be subject to required prior authorization. The January 2022 Federal
Register document was effective April 13, 2022.
II. Provisions of the Document
In accordance with 42 CFR 414.234(f), CMS may suspend DMEPOS prior
authorization requirement generally or for a particular item or items
at any time and without undertaking rulemaking. Due to the need for
certain patients to receive an orthoses item that may otherwise be
subject to prior authorization when the 2-day expedited review would
delay care and risk the health or life of the beneficiary, we are
suspending prior authorization requirements indefinitely, under these
limited circumstances:
Claims for HCPCS codes L0648, L0650, L1832, L1833, and
L1851 that are billed using modifier ST, indicating that the item was
furnished urgently.
Claims for HCPCS codes L0648, L0650, L1833, and L1851
billed with modifiers KV, J5, or J4, by suppliers furnishing these
items under a competitive bidding program exception (as described in 42
CFR 414.404(b)), to convey that the DMEPOS item is needed immediately
either because it is being furnished by a physician or treating
practitioner during an office visit where the physician or treating
practitioner determines that the brace is needed immediately due to
medical necessity or because it is being furnished by an occupational
therapist or physical therapist who determines that the brace needs to
be furnished as part of a therapy session(s).
Prior authorization will continue for these orthoses items (HCPCS
L0648, L0650, L1832, L1833, and L1851) when furnished under
circumstances not covered in this update, as well as all other items on
the Required Prior Authorization List, available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/DMEPOS_PA_Required-Prior-Authorization-List.pdf.
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document, authorizes Lynette Wilson, who is the Federal Register
Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Dated: August 5, 2022.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2022-17187 Filed 8-9-22; 8:45 am]
BILLING CODE 4120-01-P
