Power Mobility Device Prior Authorization Extended and Expanded Nationally

Posted on in Billing/Reimbursement, Legislation, Government and Advocacy

The PMD Prior Authorization Demo program was established in 2012 in seven states and was expanded to an additional 12 states in October 2014. The program included the following codes:

  • All power operated vehicles (K0800-K0802 and K0812)
  • All standard power wheelchairs (K0813-K0829)
  • All Group 2 complex rehabilitative power wheelchairs (K0835-K0843)
  • All Group 3 complex rehabilitative power wheelchairs without power options (K0848-K0855)
  • All pediatric power wheelchairs (K0890-K0891)
  • Miscellaneous power wheelchairs (K0898)

This demo program was slated to end on Aug. 31, 2018; however, prior authorization for certain PMDs will continue and be expanded nationally beginning Sept. 1, 2018, as a condition of payment. While this is a positive outcome, there are some key points worth noting:

  • Scooters are NOT included in this expansion and after Aug. 31, 2018, will no longer have prior authorization in those 19 states where it is currently available.
  • The codes included in the prior authorization condition of payment (K0813- K0855) will require a prior authorization in ALL states beginning Sept. 1, 2018.
  • K0856 and K0861 have been part of the condition of payment prior authorization since July 17, 2017, and will remain in effect.
  • Beginning Sept. 1, 2018, ADMC will no longer be available for codes K0835-K0843, K0857-K0860 and K0848-K0855.
  • The ADMC program would review the base code and all accessories; however, the condition of payment prior authorization does NOT review all accessories, rather, ONLY those accessories on which the base is contingent (example: tilt for K0835, YES; swing away mounting hardware on K0835, NO).
  • Lack of a prior authorization will result in a denial; whereas, for the PMD demo program in those 19 states, if a PA was not obtained, the claim would be developed and if approved, a 25% reduction to the allowable would apply.

U.S. Rehab, a division of VGM, will be holding a webinar on this subject in the near future to provide more details and additional information as it is released. In the meantime, if you have any questions, please contact Dan Fedor at [email protected] or 570-499-8459, or Ronda Buhrmester at [email protected] or 217-493-5440.