Orthotics and Prosthetics
- Ankle-Foot (AFO)/Knee-Ankle-Foot (KAFO) Orthosis Local Coverage Determination (LCD) and Policy Article [PDF]
- External Breast Prosthesis LCD and Policy Article [PDF]
- Eye Prosthesis LCD and Policy Article [PDF]
- Facial Prosthesis LCD and Policy Article [PDF]
- Knee Orthoses LCD and Policy Article [PDF]
- Lower Limb Prostheses LCD and Policy Article [PDF]
- Spinal Orthoses: TLSO and LSO LCD and Policy Article [PDF]
|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|
|Medical Review||View notifications and findings of pre and post claim reviews completed by Noridian Medical Review Staff|
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
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.
Last Updated May 26, 2017
The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.