CMS Updates Prior Authorization and WOPD Lists
On May 13, 2024, CMS announced in the Federal Register several updates to the Master List, Required Prior Authorization List, and Required Face-to-Face and WOPD List. This article will summarize the changes, including additions and deletions, which will be effective starting August 12, 2024.
What You Need to Know
The CMS "Master List" includes a list of DMEPOS items that are potentially subject to prior authorization and/or face-to-face and WOPD requirements. There are specific criteria that must be met for a code to be included on this list, all of which relate to potential vulnerabilities to the Medicare Trust Fund (i.e., high rate of fraud, high improper payment rate, large increase in payments, etc.). This list is updated at least once a year, and codes can either be added or removed, based on the established criteria. Last week, CMS announced that they are adding 76 HCPCS codes to the Master List, including 6 orthotic codes (L0457, L1681, L2006, L2280, L3761, and L4000) and 5 prosthetic codes (L5615, L5926, L5991, L6026, and L7366). They also announced the deletion of three codes, including one orthotic code (L1833).
Just because a HCPCS code is on the Master List does not mean that it requires a prior authorization or face-to-face/WOPD. These two requirements are established by their own, separate lists that include a subset of the codes on the Master List. When a code is deleted from the Master List, such as L1833, it must also be removed from both the prior authorization and face-to-face/WOPD lists. Along with this deletion, CMS also added 9 new HCPCS codes to the Required Prior Authorization List and 13 new HCPCS codes to the Required Face-to-Face and WOPD List. More specifically, the following orthotic codes were added/removed from each list:
Prior Authorization List
- Additions
-LSOs: L0631, L0637, and L0639
-Knee Orthoses: L1843 and L1845
-AFOs: L1951 - Deletions
-Knee Orthoses: L1833
Face-to-Face and WOPD List
- Additions
-LSOs: L0635, L0636, L0638, L0639, L0640, and L0651
-Knee Orthoses: L1845 and L1852 - Deletions
-Knee Orthoses: L1833
What this Means for You
It is important to prepare for the prior authorization and WOPD changes summarized above, which will be effective starting August 12, 2024. Although you will no longer be required to obtain a prior authorization or WOPD for L1833, there are 6 additional orthotic codes that will require prior authorization and 8 additional orthotic codes that will require a WOPD and face-to-face encounter. Along with educating your staff, it may be helpful to update your EMR system to flag these new requirements so they are not missed when submitting a claim for DOS on or after August 12. You may also need to discuss a new office protocol and workflow for these specific orthoses to ensure that the appropriate documents are requested and received prior to delivery. For more information on these changes, visit the CMS website for Prior Authorizations and DMEPOS Orders and Face-to-Face Encounters.