Article Detail - JA DME

In acute or emergent situations where a two-day expedited prior authorization review would delay care and potentially jeopardize the health or life of the beneficiary, suppliers may append the ST modifier to bypass prior authorization for orthotic claims. CMS has not provided specific examples, criteria for, or guidance on what qualifies as an acute or emergent situation; this determination is at the discretion of the treating practitioner.

In cases where a brace is required immediately after surgery, the emergent need for the brace cannot be documented until after the surgery is performed. While a brace can be ordered before the surgery, it cannot be provided until medical need is established, which only occurs after the surgery has been performed. The practitioner must document the acute or emergent need for the brace in the beneficiary’s medical record and append the ST modifier to the claim. The ST modifier indicates that the beneficiary cannot wait for prior authorization, as waiting could potentially delay care and risk the health or life of the beneficiary. Claims with the ST modifier will bypass the prior authorization process but may be subject to prepayment review.

During a prepayment review, additional documentation may be requested via an Additional Documentation Request (ADR) letter. The supplier must submit the requested documentation within 45 days of the letter’s date. Once the documentation has been received by the DME MAC, the DME MAC has 30 days to review the documentation and make a claim decision. It is crucial that all supporting documentation, including evidence of an acute or emergent need, be provided to substantiate the medical necessity of the claim.