Prior Authorization for Spinal and Knee Braces – Acute/Emergent Situations

The situation: A practitioner or physician is treating a patient who is in immediate need of a spinal or knee brace to avoid risking the health of the patient. The specific brace required is on that is on the HCPCS prior authorization list. The standard prior authorization process takes up to 10 business days. What options do you have?

The answer: In an acute/emergent situation, where delaying the patient’s care could cause harm, the supplier may use the ST modifier.

When a practitioner or physician is treating a patient who needs a brace immediately, the claim is billed with the appropriate HCPCS codes, any modifiers required per the LCD, and the ST modifier. The ST modifier indicates this treatment is related to a trauma or injury. Claims submitted with the ST modifier are subject to 100% prepayment review.

This means you may be asked for medical records to support the need to immediately treat the patient. The claim, and supporting documentation, will be reviewed prior to payment.

What Does This Mean for You?

Be aware of the prior authorization program and what dates your geographical service area is participating. Use the prior authorization process for standard cases. In those situations where the patient may be harmed by delay of care, dispense the brace, bill the claim, and use the ST modifier. Be prepared for documentation request and claim review prior to payment.

More information about the Prior Authorization process and the correct modifiers may be found here.