Tag: DME Codes

Updates to the Master List and the Required Prior Authorization List

Posted on by DME INFO

CMS announced in the Federal Register on 1/13/2026 updates to the Master List and the Required Prior Authorization List.  The Master List update includes the addition of 18 HCPCS codes effective 4/13/2026.

The Required Prior Authorization List update includes the selection of seven HCPCS codes. The additional selections include certain orthoses and pneumatic compression device items. Prior authorization as a condition of payment begins nationwide 4/13/2026 for the newly added codes.

See the Policy Groups section for more information.
See the full list of codes on the Required Prior Authorization List (PDF)
See the full list of codes on the Master List (PDF)

CORRECT CODING – DEFINITIONS USED FOR OFF-THE-SHELF VERSUS CUSTOM-FITTED PREFABRICATED ORTHOTICS (BRACES) – REVISED

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Joint DME MAC Publication

This is a revision to a previously published article 3/28/2014.

As part of the 2014 and 2015 HCPCS update, codes were created describing certain OTS orthotics. Some of these codes parallel codes for custom fitted versions of the same items. Refer to the table at the end of this article for a listing of codes.

When providing these items suppliers must:

  • Provide the product that is specified by the ordering physician
  • Be sure that the ordering physician’s medical record justifies the need for the type of product (i.e., prefabricated versus custom fabricated)
  • Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
  • Have detailed documentation in the supplier’s record that justifies the code selected

Please click here to read the entire article

 

Widespread Prepayment Probe for HCPCS Code L4360 (Pneumatic Walking Boot)

Posted on by DME INFO

DME MAC A will be initiating a widespread prepayment probe of claims for the following HCPCS code:

L4360 (WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE)

This review is being initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.  Please click here to see entire article: L4360 Probe

2015 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

Posted on by DME INFO

For CY 2015, the update factor of 1.5 percent is applied to the applicable CY 2014 DMEPOS fee schedule
amounts.  For more information and to download the 2015 DMEPOS Fee Schedule please click these links:

CMS Transmittal 3129         2015 Fee Schedule Downloads