Delivering Braces Before Medical Necessity Exists
Your patient has suffered an injury and requires outpatient surgery. You have them scheduled for the surgical procedure in two weeks. You also know today that the surgery will result in a medical need for a brace. Can you deliver the brace today? In this post, we'll give you the answer to this question.
What You Need to Know
You cannot provide a brace to a Medicare beneficiary before medical necessity exists. The DME MACs all require that patients satisfy applicable coverage criteria for prescribed itemsat the time of service. The fact that you know today exactly what the patients' post-operative bracing needs will be does not relieve you of the obligation to comply with this requirement. In other words, if you deliver an item to a patient before there's a documented medical need for it, Medicare will deny that claim.
What this Means for You
In the outpatient setting, you must wait until you can show medical necessity before providing a Medicare beneficiary a brace. If medical necessity does not exist prior to surgery, this means you cannot deliver the device until after the physician has performed the procedure. If the brace at issue is subject to prior authorization and the patient urgently requires the brace immediately after surgery, you can bypass prior authorization by using the "ST" modifier. Be aware, however, that you must thoroughly document why waiting to obtain prior authorization would pose an immediate health risk to the patient. In addition, Medicare will conduct a pre-payment review on 50% of claims you submit with the "ST" modifier. The 5 L codes subject to prior authorization are L0648, L0650, L1832, L1833, and L1851.
On the other hand, if a medical need for a brace exists pre-surgically, then you can deliver that item to the patient before the procedure. We know that some injury treatment protocols involve patients' pre-surgical use of a brace for legitimate medical reasons. In that situation, you must make sure to clearly document the pre-surgical need for the brace in order to justify delivery of that item.
We expect that some people reading this post might question whether the medical necessity standard we have outlined means that the "48-Hour Rule" has changed or is invalid. It hasn't. You can still dispense items in the hospital setting consistent with the terms and conditions of that rule. We will publish a detailed post on the 48-Hour Rule's requirements later this month.