CMS added O&P codes to its face-to-face and prior authorization lists — here is what each list actually does

The Centers for Medicare & Medicaid Services has added orthotics and prosthetics codes to three of its DMEPOS compliance lists: the Required Face-to-Face examination list, the Written Order Prior to Delivery list, and the Required Prior Authorization list. The update was reported by The O&P EDGE.

Each list is a separate mechanism. Adding O&P codes to any of them inserts a procedural step that must be completed before Medicare will pay for a device — and in the case of prior authorization, before it can be delivered at all.

What each list requires

Required Face-to-Face (RFtF) means that for the listed codes, a Medicare beneficiary must have had an in-person examination with a treating physician or other qualified practitioner within a specified period before the item is ordered. That exam needs to be documented in a way that supports the medical necessity of the specific device requested. A phone call, a telehealth note, or a prescription without an accompanying exam record does not satisfy the requirement. If the face-to-face documentation is missing or insufficient, the claim can be denied regardless of whether the clinical need is genuine.

Written Order Prior to Delivery (WOPD) means the supplier must have a valid written order from the treating practitioner in hand before delivering the item to the patient. The word “prior” is doing a lot of work in that phrase. A verbal order followed by a written order placed after delivery does not count. A retroactive order submitted at the time of billing does not count. If the device ships before the written order arrives, Medicare will not pay for it, and the documentation submitted afterward cannot fix that sequence problem.

Required Prior Authorization (PA) is the most resource-intensive of the three. Before the device is delivered, the supplier must submit a request — along with supporting documentation — to the relevant Medicare Administrative Contractor. The MAC reviews whether the item meets coverage and medical necessity requirements and issues an affirmative prior authorization decision. Delivery cannot happen until that decision comes back. If the documentation is incomplete at submission, the MAC may issue a non-affirmative decision, and the supplier has to fix the record and resubmit before proceeding.

These are layered, not interchangeable. A code on all three lists requires a face-to-face exam, a written order before delivery, and a prior authorization decision — each at a specific point in the sequence, each with its own documentation format.

Who this affects and how

The practical weight of these requirements falls unevenly. O&P clinics with established documentation systems — clear workflows for face-to-face confirmation, for tracking written orders, for managing prior authorization submissions — can absorb the additions as process updates. Smaller practices or those without dedicated billing staff face a steeper adjustment.

For patients, the more immediate question is timing. Prior authorization adds time between clinical determination and device delivery. How much time depends on the MAC, the completeness of the initial submission, and whether the documentation from the prescribing physician arrives in usable form. If the claim requires follow-up — a clarification from the prescriber, a revised diagnosis code, additional functional documentation — that adds more.

Face-to-face requirements create a different kind of pressure. They depend on a beneficiary having timely access to a treating physician who is familiar enough with the O&P pathway to document what the MAC is looking for. For someone in a rural area, someone in a post-acute care facility, or someone managing multiple conditions with a fragmented care team, scheduling that exam and having it documented correctly may not happen on the timeline a fitting requires.

Context: why the prior authorization list in particular matters

CMS has expanded its prior authorization program for DMEPOS items in phases over the past several years. The underlying rationale is reducing unnecessary utilization and improper payments for high-cost items. The documented effect, which has generated ongoing criticism from patient organizations and O&P professional associations, is that prior authorization also delays and sometimes blocks access to items that would have passed review if the documentation process went smoothly — and smoothly is not guaranteed.

Research and advocacy work in this area has consistently shown that PA denials in prosthetics and orthotics skew toward patients with more complex documentation situations, not necessarily toward patients with less clinical need. Adding more codes to the PA list extends that exposure.

This update arrives in a care environment that has already been under access pressure. A nationwide CMS moratorium on new DMEPOS supplier enrollment, which we have covered separately, limits the number of enrolled practitioners available in some markets. Prior authorization requirements are harder to manage when a patient’s only accessible enrolled supplier is at capacity or handling a high administrative backlog.

What to ask your clinic

If you’re currently in the process of getting a prosthetic or orthotic device through Medicare, the right questions to put to your clinic or billing staff are:

• Are any of the codes in my device subject to the new face-to-face, written order, or prior authorization requirements?
• Has the required face-to-face examination happened and been documented in the format the MAC expects?
• Has the written order been received before delivery is scheduled?
• If prior authorization is required, has the request been submitted, what did it include, and what is the expected turnaround?

The specific codes added to each list are documented in the CMS update and the O&P EDGE source reporting. Your clinic’s billing staff should be working from the current versions of those lists. If you’re waiting on a device and the timeline is unclear, asking which compliance step is currently pending is a reasonable and direct question — not a complicated one.

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Amputee News does not provide individualized medical, legal, billing, or insurance advice. Coverage and payment decisions depend on applicable Medicare rules, documented medical necessity, and whether required compliance steps were completed in the correct sequence. For questions about a specific prior authorization submission or decision, contact your clinic’s billing staff or your Medicare Administrative Contractor directly.