Article Detail - JA DME

CMS has given special consideration for acute situations for orthotics. Prior authorization requirements will be suspended for HCPCS codes L0648, L0650, L1832, L1833, and L1851 for the following criteria:

• When there is an acute situation where a two-day expedited review would delay care and risk the health or life of the beneficiary, a supplier may opt to bypass the prior authorization program. These claims should be billed using modifier ST and will be subject to 100% prepayment review.
• For a Physician/Practitioner or Occupational Therapist (OT)/Physical Therapist (PT)  furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), claims billed with modifiers KV, J5 or J4  would convey that the DMEPOS item is needed immediately. When submitted with one of these modifiers, 10% of claims will be subject to prepayment review.

ST Modifier- This modifier is only to be used for DME suppliers providing the codes above requiring prior authorization in an acute/emergent situation where a two-business day expedited review would delay care and risk the health or life of the beneficiary. Claims will be subject to 100% prepay review.

J4, J5, and KV Modifier - The ST modifier is not to be used by a physician/practitioner or occupational therapist (OT)/physical therapist (PT) or hospital who is a non-contract supplier with the competitive bidding program, who have the option to furnish off-the-shelf (OTS) back and knee braces to their own patients. Claims that are billed to the DME MACs by these suppliers must have the same date of service as the professional office visit or physical/occupational therapy service that is billed to the Part B MAC. The billable office visit is an absolute requirement. Claims will be subject to 10% prepayment review. The following modifiers should be used for these suppliers.

• J5 - Physical therapists and occupational therapists furnishing DMEPOS item subject to DMEPOS Competitive Bidding Program as a non-contract supplier. Professional service and DME must be billed on the same date of service.
• KV - Physicians and other treating practitioners furnishing DMEPOS item subject to DMEPOS Competitive Bidding Program as a non-contract supplier. Professional service and DME must be billed on the same date of service.
• J4 - Hospital furnishing DMEPOS item subject to DMEPOS Competitive Bidding Program as a non-contract supplier. DME must be billed on same day as discharge from hospital.

Orthotic HCPCS Codes Requiring Prior Authorization

Spinal Orthoses

• L0648 - Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf.
  • Brace is included in Competitive Bid program
• L0650 - Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
  • Brace is included in Competitive Bid program

Knee Orthoses

• L1832 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • Brace is not considered in the Competitive Bid program, as it is a custom fit item
• L1833 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
  • Brace is included in Competitive Bid program
• L1851 - Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
  • Brace is included in Competitive Bid program

Please keep in mind a prior authorization request for a brace that is needed post-operatively will be denied as not reasonable and necessary. The need for the item cannot be clearly established until the time at which the beneficiary undergoes the procedure. A supplier has two options:

1. Submit an expedited request if the beneficiary’s health/life is in jeopardy without the use of the orthotic device in the regular prior authorization review timeframe. A response will be available on the Noridian Medicare Portal or postmarked within two business days following the request.
2. If there is an emergent need, where waiting two days for an expedited decision would jeopardize the life or health of the beneficiary, the supplier may provide the brace and bill with an ST modifier. This will bypass prior authorization and will then be subject to a prepayment review.

Reference: Operational Guide and FAQs