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Orthotics

Date: 09-13-2012

  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Definitions
  • Overview

    Orthotics are used to restrict movement or support weak body parts.

    Eligible Providers

  • • Medical suppliers
  • • Indian Health Services
  • • Federally Qualified Health Center
  • • Rural Health Clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.

    Eligible Recipients

    Orthotic devices are covered for all eligible MHCP recipients.

    Covered Services

    MHCP has adopted the Medically Unlikely Edits (MUE) published by the Centers for Medicare and Medicaid Services (CMS). If CMS has not published an MUE, MHCP has established quantity limits. MHCP will not pay claims for more units per line than are allowed by the MUE or limit. When dispensing bilateral orthotics where more units are required than are allowed by the MUE or limit, the units must be billed on different lines, using modifiers NU RT and NU LT as appropriate.

    Orthotics for the spine

    Codes: L0112-L1499
    An orthotic for the spine is considered medically necessary:

  • • To facilitate healing of the spine or related soft tissues
  • • To reduce pain by restricting mobility
  • • To support weak spinal muscles or a deformed spine
  • • To treat scoliosis
  • Orthotics for the spine are covered without authorization when medically necessary with the following exceptions:

  • • HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is over $400.
  • • Repairs to an orthotic require authorization if the submitted charge is over $400.
  • Orthotics for the hip

    Codes: L1600-L1755, L2040-L2090
    An orthotic for the hip is considered medically necessary

  • • To stabilize the hip
  • • To correct and maintain hip abduction
  • One orthotic for the hip is covered per calendar year without authorization when medically necessary with the following exceptions:

  • • HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is over $400.
  • • Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is over $400.
  • • Authorization is required for the second or subsequent orthotic for the hip in any calendar year.
  • Lower limb orthotics

    Codes: L1810-L2035, L2106-L2999, L4350-L4631
    A lower limb orthotic is considered medically necessary:

  • • For treatment of contractures
  • • To immobilize a limb to promote healing
  • • To provide support and stability during ambulation
  • Four lower limb orthotics (two sets of bilateral orthotics) are covered per calendar year without authorization when medically necessary with the following exceptions:

  • • HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is over $400.
  • • Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is over $400.
  • • Authorization is required for the third or subsequent set of lower limb orthotics in any calendar year.
  • Upper extremity orthotics

    Codes: L3650-L3999
    An upper extremity orthotic is considered medically necessary:

  • • To immobilize an extremity to promote healing
  • • For treatment of contractures
  • • To provide support and stability during activities of daily living
  • Four upper extremity orthotics (two sets of bilateral orthotics) are covered per calendar year without authorization when medically necessary with the following exceptions:

  • • HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is over $400.
  • • Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is over $400.
  • • Authorization is required for the third or subsequent set of upper extremity orthotics in any calendar year.
  • Repairs to orthotic devices

    Codes: L4000-L4210
    Repairs to orthotic devices are covered without authorization with the following exceptions:

  • • Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is over $400.
  • • HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is over $400.
  • Cranial remolding orthotics

    Code: S1040
    A cranial remolding orthotic is considered medically necessary for treatment of head deformities associated with:

  • • Premature birth
  • • Restrictive intrauterine positioning
  • • Torticollis
  • • “Back to Sleep” sleeping positions
  • Up to two cranial remolding orthotics are covered without authorization for recipients under age 2. Authorization is required for the third and subsequent cranial remolding orthotic.

    Noncovered Services

  • • A prosthetic or orthotic device for which Medicare has denied the claim as not medically necessary
  • • A device whose primary purpose is to serve as a convenience to a person caring for the recipient
  • • A device that serves to address social and environmental factors and that does not directly address the recipient’s physical or mental health
  • • A device that is supplied to the recipient by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device
  • • Repair costs for a prosthetic or orthotic device that is under warranty
  • • Repair costs for any rented equipment
  • • Orthotics when used to prevent injury in a previously uninjured limb
  • • Orthotics that are to be used only during sports or other leisure activities
  • • A custom fabricated orthotic when the recipient’s needs can be met with a prefabricated orthotic
  • • Stance control orthotics (L2005)
  • • Externally powered upper extremity orthotics (L3904)
  • • Electronic /microprocessor-controlled orthotics, including the Sensor Walk, E-MAG
  • Authorization

    The following codes always require authorization if the submitted charge is over $400: L0452, L0623, L0624, L0629, L0632, L0634, L0999, L1001, L1499, L2861, L2999, L3677, L3891, L3956, L3999, L4210

    Authorization is required for quantities over the annual limit for hip, lower limb, upper extremity and cranial orthotics.

    Authorization is required for repairs to any orthotic if the submitted charge for any line using modifier RB is over $400.

    Submit authorization requests through MN–ITS (Authorization Request 278). Fax the MN–ITS response with the required documentation, physician’s orders and appropriate additional information to the medical review agent. Write the MN–ITS Authorization Request number on each page of each document.

  • • Submit the orthotic base HCPCS code with appropriate modifiers on the first line of the authorization request if a new orthotic is being requested.
  • • List all add-on items on separate lines on the authorization request. List each item by HCPCS code with appropriate modifiers, quantity and submitted charge.
  • • If requesting authorization for quantities over the annual limit, document why the additional orthotic is required, and how the requested orthotic meets the recipient’s medical and functional needs.
  • • If requesting authorization because MHCP does not have a fee schedule rate, include pricing documentation. For prefabricated orthotics, submit an invoice or Manufacturer’s Suggested Retail Price list. For custom fabricated orthotics, submit documentation of labor (in minutes) and invoices for materials.
  • • If requesting authorization for repairs document that the repair can reasonably be expected to delay replacement by at least one year.
  • • MHCP will not authorize more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When requesting authorization for bilateral orthotics where more units are required than are allowed by the MUEs, the units must be requested on different lines, with modifiers NU RT and NU LT as appropriate. Documentation must clearly establish that the greater number of units is required.
  • • When multiple items that are different but require the same miscellaneous code are requested, each item must be listed on a separate line of the authorization request. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or a narrative description up to 20 characters.
  • • Each line will be approved or denied, with the allowed dollar amount listed if approved.
  • Billing

  • • Submit claims using X12 Batch or the MN–ITS 837P Professional electronic claim.
  • • Report the ordering provider at the line level on MN–ITS Interactive claims and in Loop 2310A, segment NM109 for batch claims.
  • • If the recipient has Medicare, MHCP will pay only the deductible/co-insurance on any item for which Medicare made payment, regardless of any MHCP authorization.
  • • Shipping/delivery/set-up costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the recipient.
  • • MHCP will not pay claims for more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When billing for bilateral prosthetics where more units are required than are allowed by the MUEs, the units must be billed on different lines, with modifiers NU RT and NU LT as appropriate.
  • • When billing labor for repairs, specify the number of units and the rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.
  • • When billing for items approved on an authorization, submit one claim for all approved lines. Make sure the HCPCS codes, modifiers, and descriptions on the claim match the same information on the authorization.
  • • Enter the authorization number in the authorization field for each claim line.
  • • When the model number field is used, do not use the Notes field on the Services tab in MN–ITS. Use the Claim Notes field on the Claim Information tab.
  • • Submit the usual and customary charge for each line, not the approved amount from the authorization letter.
  • Definitions

    Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.

    Custom-made/ custom-fabricated: Made for a specific patient from his or her individual measurements and/or pattern, starting with basic materials such as plastic, metal, leather.

    Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body member or for restricting or eliminating motion in a disease or injured part of the body. Elastic support garments do not meet the definition of an orthotic because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid should be coded A4466.

    Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.

    Stock/off-the-shelf/prefabricated: Orthotic items that are not fabricated to an individual’s specifications. They may be adjusted or altered to meet the recipient’s needs, but are not made specifically for the recipient. An orthotic that is assembled solely from prefabricated components is considered prefabricated.

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