Update on Prior Authorization for Specific Bracing Codes

An Apology and Explanation 

At Össur R&R, it is our responsibility to get things right. We know you rely on the information we publish. Last week, in the wake of new guidance from Medicare about the prior authorization process for the above-listed L-codes, we got it wrong.  

Today, we give you the correct information. Also, because we believe in being open with you about why we were wrong, we will share with you what happened that led to the incorrect information getting published. We believe we owe that to you

What We Said Last Week 

Last week, the DME MACs issued new guidance regarding the prior authorization process for the codes listed above. We noted the MACs stated that in situations where the two-day prior authorization period would delay care and risk the patient’s health, suppliers can deliver these items without prior authorization. We then said that in situations where suppliers do not get prior authorization because waiting the two days to receive it would delay care and pose a risk to the patient’s health, the following standards applied to the following groups: 

• DMEPOS suppliers must use an “ST” modifier for claims submitted without prior authorization. All such claims will be subject to prepayment review. [This was and is correct.] 
• Physicians, treating practitioners, physical therapists, occupational therapists, and hospitals dispensing these braces subject to a competitive bidding exception do so by using the “KV,” “J5,” or “J4” modifiers (as applicable to each type of provider) plus the “ST” modifier. [This was incorrect, as explained more fully below.] Only 10% of claims submitted by these provider types will be subject to prepayment review. [This was and is correct.]  

The Correct Guidance 

CGS (DME MAC for Region C) has reached out to us to clarify that physicians, treating practitioners, PT’s, OT’s, and hospitals need only use the “KV,’ “J5” or “J4” modifiers (as is applicable to each provider type). These provider types do not need to additionally use the “ST” modifier. 

I would like to specifically thank Judie Roan, Provider Relations Senior Analyst for CGS (DME MAC, Region C) for initiating this outreach and providing the correct information to us. 

Our Error Explained 

Upon reading the original guidance from CMS last week, we had internal discussions about whether the “ST” modifier was required for physicians, treating practitioners, etc. in addition to the other modifiers referenced in the original guidance. We were still debating that issue when we received a screenshot from a DME MAC webinar. The webinar, which was held after publication of the original guidance, included the following statement: “When billing with the KV modifier the ST modifier is not required unless it is an emergent situation [emphasis added].”  

We interpreted this to mean that in situations where that provider could not wait for prior authorization because it would pose a health risk to the patient, the ST modifier was required in addition to the KV, J5 and J4 modifiers. Nevertheless, we published last Friday’s post without first going back to the DME MACs to get definitive guidance from them. That was our error and we take responsibility for it.

Are the Conclusions in the “What Does This Mean For You?” Section of Last Week’s Article Still Accurate? 

Yes. We said the following last week, and it remains true today: 

If you dispense a brace described by any of these codes without first getting prior authorization, you must document how delaying delivery would pose an immediate health risk to the patient to justify not using that process. If you fail to do this, prepayment review will result in a denial.  

In addition, because prepayment review requires a review of the underlying medical documentation, this process will likely lead to longer payment cycles for claims submitted outside of prior authorization. If these types of claims make up a material percentage of your total revenue today, you should prepare for short-term liquidity issues for this segment of your business. 

Finally, the approach taken by CMS – applying different prepayment claim review standards for doctors, treating practitioners, PT’s, OT’s and hospitals on the one hand, and all other supplier types on the other – signals that it is more concerned about potential abuse of the prior-authorization exemption by the latter group than the former.  

Conclusion 

I will end where I began – restating my apology to all of you. Our relationship is built on you trusting that the information we provide is correct. We take that relationship seriously (hence this update). We appreciate your loyalty. We do not take it for granted. And we will do better moving forward. Thank you for your past support of Össur R&R and, we hope, your continued engagement with it moving forward. 

David McGill
Össur R&R