Author: Clinical Policy and Programs, DMAPOS Section, DMA, 919-855-4
The following updates are in effect for the Orthotics & Prosthetics (O&P) policy to comply with the Centers for Medicare and Medicaid Services (CMS) Attending, Rendering, Ordering, Prescribing or Referring Providers Federal Regulation, 42 CFR, Part 455.410, and to clarify compliance with the CMS Home Health Final Rule, 42 CFR, Part 440.70.
1. Section 1.0 Description of the Procedure, Product, or Service, the last paragraph is replaced with the following three new paragraphs:
Refer to Attachment B for a list of HCPCS codes, established lifetime expectancies and quantity limitations for Orthotics and Prosthetics.
For the rates associated with the list of HCPCS codes found in Attachment B, refer to the Orthotics and Prosthetics fee schedule at https://dma.ncdhhs.gov/.
In compliance with the CMS Home Health Final Rule Title 42, §440.70, items not listed in Attachment B or in the Orthotics and Prosthetics fee schedule will be considered for coverage if requested by a provider, or a beneficiary through a provider, and submitted for prior authorization (PA) review of medical necessity. For beneficiaries under age 21, please request an “EPSDT review” using NCTracks. Refer to section 2.2 Special Provisions for more information about EPSDT. For beneficiaries aged 21 and older, please submit the request directly to Division of Medical Assistance (DMA) per the procedure detailed in Attachment E.
2. Section 3.2.1 Specific criteria covered by both Medicaid and NCHC, the second paragraph d. now reads:
Medical doctors (MDs), doctors of osteopathic medicine (DOs), physician assistants (PAs) and nurse practitioners (NPs) may provide certain orthotic and prosthetic devices when the devices are part of the beneficiary’s current care and treatment. These professionals may provide devices as indicated in the Required Provider Certification column of Attachment B.
3. Section 4.2.1 Specific criteria covered by both Medicaid and NCHC, contact information is updated to read:
Providers who have questions about this policy or the fee schedule located at: https://dma.ncdhhs.gov/ may contact the Durable Medical Equipment, Orthotic and Prosthetic Section of the Division of Medical Assistance (DMA) at 919-855-4310. Beneficiaries who have questions should call the Customer Service Center for Medicaid and NC Health Choice at 1-888-245-0179.
4. Sections 5.4, 5.5, 5.6, 5.7, 5.8 and all subsections, are renumbered to correct error.
5. Section 5.4 (now 5.3) Documenting Medical Necessity, the first paragraph now reads:
Medical necessity must be documented by the prescriber (physician, physician assistant, or nurse practitioner), for every item provided/billed regardless of any requirements for approval. A letter of medical necessity written and signed by the physician, physician assistant, or nurse practitioner, or other licensed professional permitted to perform those tasks and responsibilities by their NC state licensing board, may be submitted along with the CMN/PA.
6. All subsections of 5.4 (now 5.3), the first paragraph in each subsection referencing the specific section of Attachment B, are updated with this statement:
Refer to Attachment B for a list of HCPCS codes, established lifetime expectancies and quantity limitations for Orthotics and Prosthetics. To request a medical necessity review for an item not listed, see sections 1.0, 2.2 and Attachment E for instructions.
7. Section 5.5 (now 5.4) Amount of Service, now reads:
The amount of service is limited to that which is medically necessary as determined by DMA’s clinical coverage policies. Refer to Attachment B for a list of HCPCS codes, established lifetime expectancies and quantity limitations for Orthotics and Prosthetics. To request a medical necessity review for an item not listed, see sections 1.0, 2.2 and Attachment E for instructions.
8. Section 5.6 (now 5.5) Orthotic and Prosthetic Limitations, now reads:
Medicaid and NCHC may place appropriate limits, based on medical necessity criteria, on Orthotics and Prosthetics. When the prescribing physician, physician assistant, or nurse practitioner, orders equipment or supplies beyond these limits, the provider shall seek authorization for payment for these items through NCTracks.
The medical equipment provider shall submit an override request which contains the following information:
- A statement requesting an override of the quantity or life expectancy limitation and an explanation of why an override is needed.
- The item (including HCPCS code) an override is needed for.
- A prescription for the additional quantity or item the override is needed for.
- A letter of medical necessity stating the medical need for the additional quantity requested, written by the physician, physician’s assistant, nurse practitioner, or therapist.
- A copy of the remittance and status advice statement showing a denial by Medicaid or NCHC.
The override request is reviewed for appropriateness and medical necessity and a written decision, either an override letter or a denial letter, is returned to the medical equipment provider. Beneficiaries are notified in writing if the override request is denied.
Refer to Attachment B for a listing of the established lifetime expectancies and quantity limitations for Orthotics and Prosthetics. To request a medical necessity review for an item not listed, see sections 1.0, 2.2 and Attachment E for instructions.
9. Section 5.7 (now 5.6) Delivery of Service, deleted the second paragraph.
10. Section 5.8 (now 5.7) Servicing and Repairing Orthotic and Prosthetic Devices, the instructions are updated to read:
Refer to Attachment B for a list of HCPCS codes, established lifetime expectancies and quantity limitations for Orthotics and Prosthetics. To request a medical necessity review for an item not listed, see sections 1.0, 2.2 and Attachment E for instructions.
11. Subsection 5.8.2 (now 5.7.2) Repairs not Under Warranty, the third sentence now reads:
If there is no warranty, providers may request prior approval to perform the needed service and repairs by submitting a completed CMN/PA form with a repair estimate to NCTracks.
12. Subsection 5.8.3 Emergency Repairs, is outdated and deleted.
13. Subsection 5.8.4 (now 5.7.3) Replacing Orthotic and Prosthetic Devices, the second sentence of the first paragraph now reads:
The anticipated life expectancies for some of the major categories of orthotic and prosthetic devices are listed below in Attachment B.
Also, instructions a. – k. and the Note are deleted.
14. Section 6.1 Provider Qualifications and Occupational Licensing Entity Regulations, paragraph c. now reads:
MDs, DOs, PAs and NPs who are enrolled with Medicaid. These professionals may provide devices as indicated in the Required Provider Certification column of Attachment B.
15. Section 6.2 Provider Qualifications, the first paragraph now reads:
In addition to the provisions in Section 6.0, provider(s) other than MDs, DOs, PAs and NPs shall fulfill all of the following conditions to qualify for participation with Medicaid and NCHC as orthotics and prosthetics supplier(s).
16. Section 6.6, Attachment C: How a Beneficiary Obtains Orthotic and Prosthetic Devices and Attachment E: Frequently Asked Questions, are outdated and deleted. Remaining attachments are re-lettered.
17. Attachment A: Claims-Related Information, Section C Procedure Code(s), paragraph three now reads:
Refer to the Orthotic and Prosthetic Devices Fee Schedule for the rates associated with the orthotic and prosthetic devices and related supplies listed in Attachment B below. The fee schedules are available on DMA’s Web site at https://dma.ncdhhs.gov. To request a medical necessity review for an item not listed, see sections 1.0, 2.2 and Attachment E for instructions.
18. Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, physician assistant (PA) and nurse practitioner (NP) credentials are added to all the codes that can be dispensed by physicians.
19. Attachment B, HCPCS codes L0641, L0642, L0643, L0648 & L0651 currently present in the fee schedule were added to Attachment B due to being inadvertently left out during a previous update.
20. Attachment E, the procedure for Requesting Unlisted Orthotics and Prosthetics for Adults replaces the previous Attachment E, Frequently Asked Questions.
Additional Resources
Additional information is available at the North Carolina Medicaid Medical Equipment policies web page, the CMS Home Health Final Rule at 42 CFR Part 440 and the CMS Attending, Rendering, Ordering, Prescribing or Referring Providers Federal Regulation at 42 CFR, Part 455.410.