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The change comes after CMS received feedback from stakeholders highlighting the burdensome and repetitive nature of the forms, along with major rural difficulties.
August 24, 2022
3 Min Read
Image courtesy of Panther Media GmbH / Alamy Stock Photo
On Aug. 17, the Centers for Medicare & Medicaid Services (CMS) announced the discontinuation of certain Certificates of Medical Necessity (CMNs) and Durable Medical Equipment (DME) Information Forms (DIFs) for claims with a service date on or after Jan. 1, 2023. A CMN is documentation from a physician which Medicare requires before covering certain DME, prosthetics, orthotics, and supplies (DMEPOS) and states the patient’s diagnosis, prognosis, reason for equipment, and estimated duration of need. DME include equipment such as wheelchairs and scooters.
The change coincides with the goal from the Biden-Harris Administration of improving access to quality and affordable healthcare through a quicker path to necessary medical supplies for Medicare beneficiaries. Prior to 2022, section 1834(a)(15) of the 2015 final rule 80 FR 81674 included a list of DMEPOS items that were often ordered before it was known if the equipment was medically necessary and were consequently required to have prior authorization.
“CMS has concluded, however, that even the two-day expedited prior authorization review for these items could delay care enough to risk the life or health of the patient,” the American Academy of Professional Coders (AAPC) wrote.
As of April 13, 2022, prior authorization is no longer required for specified orthoses items as a condition of payment under certain circumstances when reported with specific modifiers. Now, after reaching out to stakeholders, CMS received feedback stating that completing CMNs and DIFs were burdensome to do and would duplicate information already available in a claim or medical record. Additionally, small or rural providers without access to administrative staff and technical support found it increasingly difficult to complete the forms. In response, CMS evaluated the options available to ease the process and eventually determined it could discontinue the forms. After the date of change for the discontinuation, medical necessity information and coverage criteria for a service will be found on the claim or in the medical record. After the Jan. 23, 2023, start date, all claims that include CMN or DIF information will be rejected and returned to the supplier.
Specifically, CMS will suspend prior authorization indefinitely under claims for HCPCS Level II codes L0648, L0650, L1832, L1833, and L1851 that are billed using modifier ST which indicates the item was furnished urgently. Also no longer needing prior authorization are claims for HCPCS Level II codes L0648, L0650, L1833, and L1851 billed with modifiers KV, J5, or J4 by suppliers obtaining items under a competitive bidding program exception “as described in 42 CFR 414.404(b), to convey that the DMEPOS item is needed immediately either because it is being furnished by a physician or treating practitioner during an office visit where the physician or treating practitioner determines that the brace is needed immediately due to medical necessity or because it is being furnished by an occupational therapist or physical therapist who determines that the brace needs to be furnished as part of a therapy session(s),” AAPC wrote.
Prior authorization will continue for L0648, L0650, L1832, L1833, and L1851 when used under circumstances not covered in the discontinuation update, as well as all other items found on the Required Prior Authorization List.
The CMSs and DIFs that will no longer be required in 2023, according to CMS, include:
CMS-484 – Oxygen
CMS-846 – Pneumatic Compression Devices
CMS-847 – Osteogenesis Stimulators
CMS-848 – Transcutaneous Electrical Nerve Stimulators
CMS-849 – Seat Lift Mechanisms
CMS-854 – Section C Continuation Form
CMS-10125 – External Infusion Pumps
CMS-10126 – Enteral and Parenteral Nutrition
About the Author(s)
Managing Editor, MD+DI
Katie Hobbins is managing editor for MD+DI and joined the team in July 2022. She boasts multiple previous editorial roles in print and multimedia medical journalism, including dermatology, medical aesthetics, and pediatric medicine. She graduated from Cleveland State University in 2018 with a bachelor's degree in journalism and promotional communications. She enjoys yoga, hand embroidery, and anything DIY. You can reach her at [email protected].
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