Article Detail - JA DME

In acute or emergent situations when a two-day expedited prior authorization review would delay care, risking the health or life of the beneficiary, suppliers can append the ST modifier to bypass prior authorization on orthotic claims. CMS did not provide examples or parameters for acute or emergent situations; they are allowing that to be determined by the practitioner.

In scenarios where a brace is needed immediately after surgery, the emergent need cannot be documented until after the surgery has been performed. The brace may be ordered prior to the surgery; however, the brace cannot be provided until medical need exists, which would be after the surgery. The treating practitioner must document the acute/emergent need in the medical records and append the ST modifier to the claim line. This claim will then be excluded from review under the prior authorization program but may be subject to prepayment review.

During a prepayment review, additional documentation may be requested via a letter. The supplier must submit the requested documentation within 45 days of the letter’s date. Once the documentation is received from the supplier, the DME MAC has 30 days to review the documentation and make a 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.