An updated version of Clinical Coverage Policy 5B, Orthotics and Prosthetics with an effective date of Feb. 1, 2022, was posted to the NC Medicaid Clinical Coverage Policy web page. Following is a summary of updates:
In Attachment A: Claims-Related Information, Section B International Classification of Diseases and Related Health Problems, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS), updated ICD-10 CM codes listed for diabetic shoes, inserts, and/or modifications, ankle or foot orthoses, prosthetic shoes and external breast prostheses.
In Subsection 5.6 Delivery of Service, added subsections 5.6.1 Delivery Directly to the Beneficiary and 5.6.2 Utilizing Delivery or Shipping Service to policy. This update specifies expectations for training and fitting of orthotic and prosthetic devices and clarifies what supply items are appropriate to mail beneficiaries along with clarifying expectations when using shipping services.
In Subsection 6.2 Provider Qualifications and Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, made corrections to the names of certifying boards and the credentials they issue.
In Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, Section P, Ocular Prostheses, added Certification in Clinical Anaplastology (CCA) credentials to the ocular prostheses HCPCS codes as an appropriate provider to dispense ocular prosthetics.
In the HCPCS code tables of Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, the following was removed from Attachment B: Asterisks (*) denoting HCPCS procedure codes that require prior approval and plus signs (+) denoting HCPCS procedure codes that require prior approval for an adult. Bold codes denoting items covered by Medicare were also removed from Attachment B.
The fee schedule is an updated reference for HCPCS codes that require prior approval.
In Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices in the Required Provider Certification column of the HCPCS code tables, updated certifications required for dispensing each HCPCS code. For a detailed summary of certification changes, please refer to 8.0 Policy Implementation/Revision Information.
In Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, updated HCPCS code descriptions in the HCPCS code tables of Attachment B per the HCPCS Level II 2020 edition reference. For a list of codes that had the description updated, please refer to 8.0 Policy Implementation/Revision Information.
In Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, added prefabricated, off-the-shelf HCPCS codes from the CMS 2014 update that were paired with existing covered codes. Revision is effective Jan. 1, 2014. For a list of these codes that are a part of this update, please refer to 8.0 Policy Implementation/Revision Information.
Additional Resources
The Orthotic and Prosthetic fee schedule and full text of Clinical Coverage Policy 5B Orthotics and Prosthetics is available at North Carolina Medicaid’s Orthotics and Prosthetics web page.
Contact
NC Medicaid Contact Center, 888-245-0179