Monthly Archives: March 2017

Prior Authorization Condition of Payment for K0856 and K0861

By: Kim Turner, RN – Clinical Consultant

CMS has announced that two items of durable medical equipment will be subject to required prior authorization beginning with dates of service/delivery March 20, 2017 for the following durable medical equipment:

  • K0856: Power wheelchair, group 3 standard., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
  • K0861: Power wheelchair, group 3 standard., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Suppliers submitting claims for beneficiaries residing in any of the four states listed below must receive prior authorization affirmation as a condition for payment before the item can be furnished or a claim can be submitted:

  • Jurisdiction A, New York
  • Jurisdiction B, Illinois
  • Jurisdiction C, West Virginia
  • Jurisdiction D, Missouri

CMS also announced its intent to expand the prior authorization process for codes K0856 and K0861 nationwide in July 2017.

Documents required for submitting a Prior Authorization request include:

  • Prior Authorization Cover Sheet- a copy of the coversheet can be down-loaded from the applicable jurisdiction Medicare web site (A, B, C, D)
  • Face to Face power mobility exam completed including the required stamped received date.
  • Completed 7 element order including the required stamped received date.
  • Completed (signed and dated) Detailed Product Description including the required stamped received date.
  • LCMP specialty evaluation completed by PT, OT, or physician with experience in completing mobility evaluation. Physician must state concurrence, sign and date the LCMP exam in order to incorporate into the face to face exam. Include the required stamped received date on each page of the LCMP evaluation.
  • ATP Evaluation with proof supplier employees RESNA certified ATP and their involvement.
  • Financial Attestation between the supplier and LCMP.
  • Other relevant medical documents addressing the beneficiary’s mobility related abilities and policy criteria

A completed home evaluation is not required for submitting the request for prior authorization.  The home evaluation can be completed prior to or at delivery.

Jurisdiction will review and complete the Prior Authorization request in 10 business days. Supplier is able to request an expedited request with supporting medical documentation explaining why an expedited prior authorization is required.  An expedited prior authorization request will be processed in 2 business days. Affirmative or Non-affirmative decision letter will be issued to the supplier.

Resubmissions for prior authorization are unlimited.

RAC Record Requests

By: Lisa Eick, RN – Clinical Consultant

So, the RACs are back! What does this mean for the home medical equipment, home health and hospice providers? As of this writing there are no issues approved by CMS for the RAC, Performant, for home health and hospice, although DME isn’t so lucky (see previous blog post). The first RAC audits will begin in March, and new ones will not begin until CMS approves the issues and notifies Performant.

What is important for suppliers and agencies to understand is how CMS calculates the number of claims for ADR review.

  • The baseline annual ADR limit is one-half of one percent (0.5%) of the provider’s total number of Medicare claims paid in the previous year. This is determined by the six-digit CMS Certification Number (CNN) or Provider Transaction Access Number (PTAN) and the provider’s National Provider Identifier (NPI) number.
  • ADR letters are sent to providers on a 45-day cycle. RACs may go longer than 45 days between cycles but not less than 45 days between ADR requests.
  • ADR limits are determined by all claim types based on the types of bills submitted in the previous year. The look-back period is limited to three years from the date the claim was paid using the 0.5% baseline criteria.
  • After three, 45-day cycles, the adjusted ADR limits are determined. The provider denial rate is calculated, which identifies compliance with CMS requirements. It is calculated by using the number of claims that were improperly paid (minus any overturned during appeal) divided by the total number of claims reviewed. The adjusted ADR is used for the next three ADR cycles.
  • RACS may choose to conduct reviews on either the annual ADR limit or the adjusted ADR limit. If using the adjusted ADR limit, a six-month look-back period is used for review. When using the annual ADR limit, the recovery auditors use a three-year look-back period.

As providers prepare for the return of the RACS, remember The van Halem Group has both proactive and reactive RAC audit protection services available to suppliers and providers. Please contact us for more information at (404) 343-1815 or

Source:; accessed 2/21/17.