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Orthotics and Prosthetics

Coverage

Documentation

Document Type Description
AFO/KAFO Documentation Checklist [PDF] This checklist describes documentation needed for AFO/KAFO claims
Artificial Limbs Physician Letter [PDF] This letter to physicians describes the required documentation for a prosthetic device
External Breast Prosthesis Documentation Checklist [PDF] This checklist describes documentation needed for External Breast Prosthesis claims
Knee Orthosis Documentation Checklist [PDF]  This checklist describes documentation needed for Knee Orthosis claims 
Lower Limb Prosthesis Documentation Checklist [PDF] This checklist describes documentation needed for Lower Limb Prosthesis claims
Spinal Orthosis Documentation Checklist [PDF] This checklist describes documentation needed for Spinal Orthosis claims

 

Reviews/Audits

Review Type Description
Medical Review View notifications and findings of pre and post claim reviews completed by Noridian Medical Review Staff

 

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Concentric Adjustable Torsion Joints - Correct Coding

Concentric adjustable torsion-style joints used solely to provide an assistive function for joint motion must be coded L2999 or L3999. When concentric adjustable torsion-style joints are used for any condition other than to provide an assistive function for joint motion, they must be coded as durable medical equipment using the following codes:

E1800 – Dynamic adjustable elbow extension/flexion device
E1802 – Dynamic adjustable forearm pronation/supination device
E1805 – Dynamic adjustable wrist extension/flexion device
E1810 – Dynamic adjustable knee extension/flexion device
E1815 – Dynamic adjustable ankle extension/flexion device

Cosmetic Features

Suppliers should be billing L6895 [addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated] for upper limb prosthetic cosmetic features such as; coloring, veins, hair, etc.

HCPCS L6895 is the appropriate code to bill for a prosthetic cosmetic glove including matching color, hair, skin, and wrinkles. Suppliers should NOT bill using HCPCS L7499 for the cost of the additional cosmetic features. The long narrative description for the L6895 indicates "any material" and therefore includes all of these cosmetic features.

Custom Fitted Orthosis

Suppliers who are performing substantial modifications for a custom fitted orthosis must be a certified orthotist or someone with equivalent specialized training such as a physician, treating practitioner, physical therapist or occupational therapist, etc. A certified fitter would not meet this requirement.

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Resource

Last Updated Apr 13, 2017

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