Medicare, in its attempt to stem payments to providers and reduce fraud and abuse, CMS has now expanded its DMEPOS Prior Authorization program to include HCPCS L1951, a very specific type of AFO distributed by KevinRoot Medical. For more information, go to the KevinRoot Medical Forum.
L1951is defined as an Ankle foot orthosis (AFO), spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment. (Insert a photo)
This device was one of many HCPCS codes which Medicare added to its DMEPOS Master List and subsequently is to be included into a mandatory prior authorization process as of August 12, 2024.
The exact process for submitting prior authorization will be similar to those of commercial and Medicare replacement programs. Medicare DMEPOS carriers already have a provider portal, which is essential to a seamless process to obtain prior authorization. If you don’t already have the portal and have been delaying obtaining access to DMEPOS or other third-party portal, this should your impetus to navigate the process and gain access.
Using the Medicare DMEPOS portals (MyCGS for DME MAC B/C and Noridian’s for DME MAC A/D) allows you do the following for free:
Verify eligibility, check deductible status (QMB patient are the exception), convert from SSN to current Medicare Number, check for same or similar, submit prior authorization and submit claim appeals and much more.
By using the portal, you will be provided with the confidence that you can not only submit your documentation in a HIPAA compliant fashion but also track its progress through the process.
For patients with an urgent (or emergent) need for an L1951, there is a question into CMS as to whether the existing ST (stat) modifier used for knee and spinal braces can be utilized. It may take a few months for CMS to respond to this inquiry, so stay in touch with this forum for a follow up. Please note that the DMEPOS prior authorization process typically takes 3-5 days (depending on whether or not you tag it as urgent). If the ST modifier is accepted for L1951, it is imperative to understand that those claims may be subject to a mandatory pre-payment review.
There are many other HCPCS codes subject to prior authorization and they should periodically check the CMS website for a more thorough discussion.
Documentation as with all things DME is crucial. More on that in the next edition of the forum.
