Prior Authorization (K0856 and K0861) UTN ALERT

Originally when the Condition of Payment Prior Authorization Program for K0856 and K0861 was implemented (Nationally on July 17, 2017), it was noted that the Unique Tracking Number (UTN) provided with the affirmation letter could be included in loop 2300 OR loop 2400 on the claim.  This is how it was noted in the CMS Prior Authorization Operational Guide.

However, if the UTN was placed in loop 2300 and populated all lines including the accessories, CGS DME MAC for B and C would deny the accessories because the UTN does not apply to the accessories; the UTN only applies to the base code (K0856 / K0861). On September 6, 2017, CGS (MACs B and C) issued an FAQ Update stating that the UTN for this prior authorization program should be placed in loop 2400 and only for the base code lines (K0856 / K0861) to avoid denials of the accessories. At that time, Noridian did not issue any notice, as they were still accepting the UTN in either loop 2300 or loop 2400. Recently, Noridian stated that they will also be notifying providers in jurisdiction A and D to place the UTN in loop 2400 for the base code line ONLY to avoid “issues” with the accessories.

When questioned as to why the process is different from what the CMS operational guide instructs, we were informed that the operational guide was incorrect and would be updated to reflect that the UTN must only be in loop 2400 for the base code line. If you are submitting to A or D MAC and have not yet experienced denials of the accessories, please note that it is a matter of time before it begins in A and D. Talk with your software vendor to ensure that the PA National Program (codes K0856 and K0861) will allow for the UTN to be placed in loop 2400 for the base code only!

If you have been in a PMD Demo Par State for the past several years, you may have noticed the accessories are not denied if the UTN is in loop 2300. The reason for this is because programming logic does NOT apply to the PMD Demo Project, as they will accept the UTN in either field.

If you have any questions please contact Dan Fedor at dan.fedor@vgm.com or 570-499-8459.

Dan Fedor
Reimbursement Specialist, U.S. Rehab
O: 844-794-8459
C: 570-499-8459
E: mailto:dan.fedor@vgm.com
F: 844-307-5729