Medicare Suspends Prior Authorization Requirements for Some DME
- By Lee Fifield
- In Billing
- August 15, 2022
- 4 Comments
Prior authorization is no longer required for certain DME when it risks the health of the patient.
The Centers for Medicare & Medicaid Services (CMS) has suspended the prior authorization requirements for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when waiting for prior authorization would delay healthcare and risk the life or health of the patient.
As of April 13, 2022, prior authorization is no longer required for specified orthoses items that used to require prior authorization as a condition of payment under certain circumstances when reported with certain modifiers. (This does not apply to items subject to a face-to-face encounter and written order prior to delivery requirements.)
Codes Affected
Prior to this year, section 1834(a)(15) of the 2015 final rule 80 FR 81674 titled, “Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies,” was implemented. It included a list of DMEPOS items that were often ordered without being medically necessary and were therefore required to have prior authorization.
CMS has concluded, however, that even the two-day expedited prior authorization review for these items could delay care enough to risk the life or health of the patient. As a result, CMS is suspending prior authorization requirements indefinitely under the following limited circumstances:
- Claims for HCPCS Level II codes L0648, L0650, L1832, L1833, and L1851 that are billed using modifier ST, indicating that the item was furnished urgently.
- Claims for HCPCS Level II codes L0648, L0650, L1833, and L1851 billed with modifiers KV, J5, or J4, by suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), to convey that the DMEPOS item is needed immediately either because it is being furnished by a physician or treating practitioner during an office visit where the physician or treating practitioner determines that the brace is needed immediately due to medical necessity or because it is being furnished by an occupational therapist or physical therapist who determines that the brace needs to be furnished as part of a therapy session(s).
Prior authorization will continue for orthoses items L0648, L0650, L1832, L1833, and L1851 when furnished under circumstances not covered in this update, as well as all other items on the Required Prior Authorization List.
Resources:
- Lincare Holdings to Pay $29 Million for Medicare Overbilling - September 20, 2023
- Taking an AAPC Exam in 2024? A Change Is Coming. - September 6, 2023
- Advice From a CHONC™ - September 1, 2023
The author did not include important information that all DMEPOS items billed with ST modifier are under 100% review by Medicare. Suppliers need to validate documentation of medical necessity by the ordering provider in order to assure compliance with the LCD guidelines. Also, the author does not mention that the same DME items that can utilize the ST modifier are also on the Face-To-Face and WOPD list: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf
To restate, L0648, L0650, L1832, L1833, L1951 may be furnished urgently with the ST modifier but they also must comply with the Face-to-face guidelines and have a written order prior to delivery. and also are subject to 100% review for compliance with LCD guidelines.
It’s Medicare insurance so the payer no need of prior Authorisation for any durable good or DME services because the patient have already submitted the ABN to payer. If Medicare doesn’t pay means patient responsibility to make an payment so they need proof of delivery i.e, ABN with provider and patient on with date of service mentioned on it.
How do we know what modifiers and procedures do not require prio authorization?
Refer to the prior authorization list; the link is given at the end of the article.