Condition of Payment Prior Authorization Expands to Include Select Orthotics

In December 2016, CMS issued a final rule that established a Condition of Payment Prior Authorization (COPPA) process for certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) that are frequently subject to unnecessary utilization. This process was implemented in March 2017 for two HCPCS codes and expanded to include 51 items as of December 2020.

CMS published a notice in the Federal Register January 13 adding the following orthotics HCPCS codes to COPPA program: Lumbosacral Orthoses L0648 and L0650 and Knee Orthoses L1832, L1833, and L1851.

Implementation of prior authorization (PA) for these codes will occur in three separate phases.

Phase I will require beneficiaries residing in California, Florida, Illinois, and New York to have a PA on file prior to providing and billing these orthoses.

Phase II is effective for dates of service on or after July 12, 2022, for Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington.

Phase III expands nationwide effective for dates of service on or after October 10, 2022.

See the Medicare Learning Network (MLN) article SE20007 for additional information on the COPPA expansion.

            Last Updated Mon, 28 Feb 2022 16:44:30 +0000