The Centers for Medicare & Medicaid Services (CMS) announced the suspension of prior authorization requirements for specified orthoses prescribed and furnished urgently or under special circumstances. The announcement, first addressed in April, is now included in the Federal Register.
“Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two-day expedited review would delay care and risk the health or life of the beneficiary,” CMS said it was suspending prior authorization requirements under limited circumstances:
- Claims for Healthcare Common Procedure Coding System (HCPCS) codes L-0648, L-0650, L-1832, L-1833, and L-1851 that are billed using modifier ST, indicating that the item was furnished urgently.
- Claims for HCPCS codes L-0648, L-0650, L-1833, and L-1851 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 the listed HCPCS items when they are furnished under circumstances not covered in the update, as well as all other items on the Required Prior Authorization List.
The suspension was first announced in April, after the American Orthotic & Prosthetic Association (AOPA) raised concerns about prior authorization’s effects on patient care.
To read the April story, visit “AOPA Addresses CMS Spinal, Knee Orthosis Prior Authorization.”