Prior Authorization for PMD Codes K0856 and K0861 to Begin in March 2017!

Posted on in Billing/Reimbursement

By Dan Fedor, U.S. Rehab

CMS has announced that prior authorization (PA) for power wheelchair codes K0856 (Group 3 single power option) and K0861 (Group 3 multiple power option) will begin in March in New York, Illinois, Missouri and West Virginia. It is expected to go nationwide in July.

PA requests from New York, Illinois, Missouri and West Virginia will be accepted beginning March 6 for dates of service on or after March 20. If you service Medicare beneficiaries who reside in one of these first four states, please be prepared to submit for prior authorization for these codes, otherwise the claims will be denied. 

The differences between ADMC (Advance Determination of Medicare Coverage) and PA include the following:

  • ADMC is optional, while PA is required. Once PA is implemented (either in March or July), you MUST use the PA process for codes K0856 and K0861 or the claim will be DENIED. 
  • ADMC requests require a home assessment, while PA does not require a home assessment with the request. A home assessment may be performed AFTER the PA determination (prior to or on the delivery date). 
  • ADMC allowed only two submissions within a six-month period, while PA offers unlimited submissions. 
  • ADMC has a 30-day response time, while PA has a 10 business day response time for initial submissions and subsequent requests within 20 days.  

Noridian, DME MAC for jurisdictions A and D, has issued a very comprehensive guide to the prior authorization request process. Please click here to access this guide. While this guide is from Noridian, the content applies to all DME MACs.

If you have any question regarding this information, please contact me at the contact information below:

Office: 844-794-8459

Cell: 570-499-8459

Email: [email protected]