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.