CMS Posts Document for DMEPOS Providers 

CMS posted the document, Updates to the Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements; Updates to the Required Face-to-Face and Written Order Prior to Delivery List; and Updates to the Required Prior Authorization List in the Federal Register on May 3, 2024.  The overall effective date of the rule is August 12, 2024. 

Please see the following for highlights of the CMS document.  DME providers are encouraged to review the entire document in the Federal Register to understand all regulatory compliance requirements. 

Read the document at https://www.govinfo.gov/content/pkg/FR-2024-05-13/pdf/2024-10356.pdf 

Summary:  

• This document announces the updated Healthcare Common Procedure Coding System (HCPCS) codes on the Master List.  
• It also announces updates to the HCPCS codes on the Required Face-to-Face and Written Order Prior to Delivery List and the Required Prior Authorization List.  
• This document serves to update three separate lists.  
  • It provides an update to the Master List.  
  • It updates the items included on the Required Face-to-Face and Written Order Prior to Delivery List.  
  • It updates items included on the Required Prior Authorization List. 

Specific Implementation Dates: 

• Implementation of updates to the Master List and the Required Face-to-Face and Written Order Prior to Delivery List are effective on August 12, 2024.  
• Required prior authorization of newly added lumbar-sacral orthoses and lower limb orthoses is effective nationwide on August 12, 2024. 
• Prior authorization of newly added osteogenesis stimulators will be implemented in two phases, with phase 1 including one State per Durable Medical Equipment Medicare Administrative Contractor (DME MAC) jurisdiction on August 12, 2024. 
  • The States included in Phase 1 are California, Florida, Ohio, and Pennsylvania. Phase 2 will include all remaining U.S. States and territories not included in Phase 1, effective on November 12, 2024 

The States included in Phase 1 are California, Florida, Ohio, and Pennsylvania. Phase 2 will include all remaining U.S. States and territories not included in Phase 1. 

Provisions of this document 

Master List Update 

• This document provides the annual update to the Master List of DMEPOS Items Potentially Subjected to a Face-to-Face Encounter and Written Order Before Delivery and/or Prior Authorization Requirements stated in the November 2019 final rule (84 FR 60648).  
• CMS adjusts the “payment threshold” each year for inflation.  
  • Specifically, the $500 average purchase fee threshold and the $50 average monthly rental fee threshold are adjusted using the consumer price index for all urban consumers (CPI–U), reduced by the 10-year moving average of changes in annual economy-wide private nonfarm business multifactor productivity (MFP) as projected by the Secretary for the 10 years ending with the applicable FY, year, cost reporting period, or other annual period. 
• The DMEPOS fee schedule amounts are also updated every year to account for inflation (see pages 41324-41325 in the Federal Register notice). 
• CMS is adding a total of 76 HCPCS codes meeting the designated criteria for the Master List (see pages 41326-41327 in the Federal Register notice for additions and deletions) 
  • Of these 76 HCPCS codes, 56 are added because these items meet the updated payment threshold and are listed in an OIG or GAO report of national scope or a CERT Medicare Fee-for-Service Supplemental Improper Payment Data report, or both; and 20 are being added to aberrant billing patterns.  
  • The codes added due to aberrant billing patterns represent items for which data show suppliers submitted at least 1,000 claims and received at least $1 million in payments during the two 12-month periods from July 2021 to June 2022 and July 2022 to June 2023. There was more than a 30 percent increase in payments for each item in the preceding 12-month period. CMS did not identify explanatory contributing factors for the aberrant billing. 
• Item deletion from the Master List 
  • Items are removed from the Master List 10 years after the date the item was added unless 
    •  The item was identified in an OIG report, GAO report, or
    •  has been identified in the CERT Medicare Fee-for-Service Supplemental Improper Payment Data report as having a high improper payment rate, within the 5 years preceding the anticipated date of expiration. 
• Items are removed from the list sooner than the 10-year timeframe if the purchase or monthly rental amount drops below the payment threshold. There are three (See Table 2) HCPCS codes being removed from the Master List for the CY 2024 update, as they no longer meet the criteria for inclusion. 

The full updated Master List is available in the Downloads & Links section of the following CMS website: http://go.cms.gov/DMEPOSPA 

Items Subject to Face-to-Face Encounter and Written Order Prior to Delivery Requirements 

• CMS is adding the following 13 additional HCPCS codes to the F2F/WOPD List (See page 41328 in the Federal Register notice for the list). 
• CMS selected codes for three hospital beds, two osteogenesis stimulators, six lumbar sacral orthoses, and two knee orthoses.  
• CMS continues to believe additional practitioner oversight of beneficiaries in need of items included on the F2F/WOPD List will help further our program integrity goals of reducing fraud, waste, and abuse.  
  • It also helps ensure beneficiary receipt of items specific to their medical needs, as the written order/prescription must be communicated to the supplier before delivery. For such items, we continue to require the treating practitioner to have a face-to-face encounter with the beneficiary within the 6 months preceding the date of the written order/prescription. 

The F2F/WOPD List is available on the CMS website: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf 

Items Subject to Prior Authorization Requirements – Updates 

• CMS added nine HCPCS codes Prior Authorization Requirements (see page 41329 of the Federal Register notice for additions)  
  • CMS removed HCPCS code L1833 from the Required Prior Authorization List as the item no longer meets the criteria to be maintained on the Master List and is no longer eligible for inclusion.  
• The remaining 61 HCPCS codes currently on the Required Prior Authorization List remain on the List without interruption.  
• CMS will issue specific prior authorization guidance for these additional items in sub-regulatory communications, final timelines customized for the DMEPOS item subject to prior authorization, and for communicating a provisionally affirmed or non-affirmed decision to the requester. 

The updated Required Prior Authorization List is available in the Downloads & Links section of the following CMS website: http://go.cms.gov/DMEPOSPA