Earlier this year, CMS revised its Master List of DMEPOS Items Potentially Subject to Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements.
That is a terrible name for a list. Let’s just call it the Master List. Moving on …
While the name is confusing, the actual purpose and use is straightforward. In short, the Master List standardizes the process of identifying financially significant DME items CMS can subject to additional conditions of payment. Suppliers that do not understand the process risk doing too much, or too little, to document proper claims. Both are bad for the bottom line.
Making the Master List
The Master List is a list of HCPCS codes that are eligible for additional conditions of payment, namely prior authorization and face-to-face encounters and written orders prior to delivery.
To determine which codes CMS should add or remove from the Master List, the agency periodically reviews item specifications and claim data. HCPCS codes that meet any of the following criteria are included on the Master List:
To include items subject to the 1.5 percent threshold, one of the following entities must also identify a spike in billing volume suggesting overutilization or possible fraud:
The Master List Doesn’t Require Additional Conditions of Payment
The Master List, in and of itself, imposes no additional conditions of payment. Its purpose is to identify eligible codes using standardized criteria. Once on the Master List, CMS can elect to subject specific codes to additional requirements via two sublists:
I included detailed updates on both sublists in the February 2022 edition of (K)notes, which you can check out here (access requires separate registration or an active (K)notes/(K)notes Plus subscription).
That is a terrible name for a list. Let’s just call it the Master List. Moving on …
While the name is confusing, the actual purpose and use is straightforward. In short, the Master List standardizes the process of identifying financially significant DME items CMS can subject to additional conditions of payment. Suppliers that do not understand the process risk doing too much, or too little, to document proper claims. Both are bad for the bottom line.
Making the Master List
The Master List is a list of HCPCS codes that are eligible for additional conditions of payment, namely prior authorization and face-to-face encounters and written orders prior to delivery.
To determine which codes CMS should add or remove from the Master List, the agency periodically reviews item specifications and claim data. HCPCS codes that meet any of the following criteria are included on the Master List:
- Purchase price is $500 or more,
- Average monthly rental price is $50 or more, or
- Total Medicare payments for the HCPCS code in a 12-month period equal more than 1.5 percent of Medicare expenditures for all DME items in the same period.
To include items subject to the 1.5 percent threshold, one of the following entities must also identify a spike in billing volume suggesting overutilization or possible fraud:
- Office of Inspector General.
- Government Accountability Office.
- Comprehensive Error Rate Testing (CERT) contractor.
The Master List Doesn’t Require Additional Conditions of Payment
The Master List, in and of itself, imposes no additional conditions of payment. Its purpose is to identify eligible codes using standardized criteria. Once on the Master List, CMS can elect to subject specific codes to additional requirements via two sublists:
- Required Prior Authorization.
- Required Face-to-Face Encounter and Written Order Prior to Delivery (FTF/WOPD).
I included detailed updates on both sublists in the February 2022 edition of (K)notes, which you can check out here (access requires separate registration or an active (K)notes/(K)notes Plus subscription).
In the end, suppliers can think of the Master List like the ball used to jumble the numbers in bingo and the sublists are the bingo cards. All possible codes go into the ball, but only the codes on the sublists are in active play and subject to prior authorization or FTF/WOPD.
SOURCE LINKS
2022 Update to the Master List and Changes to Companion Lists - https://www.govinfo.gov/content/pkg/FR-2022-01-13/pdf/2022-00572.pdf
2019 CMS Rule (CMS-1713-F) that created the SWO, Master List and Companion Required Lists - https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf
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