New Information on KV Modifiers

Physicians do not do prior auth, pre-pay audits are happening, and a DMEPOS CB contracted provider must supply post-op braces.

CMS and DME MACs have clarified information about the competitive bid program, how it impacts non-contracted CB physicians providing braces to their patients, and who is required to do prior authorization.

First, a review, braces billed with L1833, L1851, L0648, and L0650 are part of the Competitive Bid program and require prior authorization by a contracted competitive bid supplier. Physicians may dispense braces billed with these HCPCS codes to their patients, as part of the patient’s treatment, on the same day of service that an office visit is billed.

The latest information from CMS indicates that physician offices cannot obtain prior authorization. The physician documents the need for the brace provides it to their patient and bills the DMEPOS claim with modifier KV and any other modifiers required for the brace. The physician also bills an office visit, to Part A/B, with the same date of service.

Ten percent (10%) of the claims submitted with a KV modifier will be subject to pre-payment review. This means the DME MAC will hold 10% of those claims, mail a letter requesting additional documentation from the physician’s office (called an ADR,) give the office 45 days to respond, and then review the documentation to determine the medical necessity of the brace.

The DME MACs will deny the claim if a response to the ADR if the physician’s office does not respond within 45 days. Important to note: ADRs are mailed to the remit address you provided during supplier enrollment. If that remit address is a lockbox, you may not receive the ADR letters promptly. In other words, check your snail mail often.

The DME MACs have also clarified the only suppliers able to bill for a post-op brace are Competitive Bid Suppliers. The supplier must obtain prior authorization for the brace and submit the claim, with the surgery date as the date of service.

What Does This Mean for You?

First, ensure you know the medical necessity requirements for the braces billed with the HCPCS mentioned above. Read the LCDs for the details.

Secondly, when dispensing one of these braces, use the KV modifier and bill an office visit the same day.

Finally, check your remit address on file with the National Supplier Clearinghouse and make sure there is a process for quickly identifying ADR letters.