Updates to Clinical Coverage Policy 5B Orthotics and Prosthetics

An updated version effective Sept. 1, 2022, has been posted to the NC Medicaid Clinical Coverage Policy web page.

An updated version of Clinical Coverage Policy 5B, Orthotics and Prosthetics effective Sept. 1, 2022, has been posted to the NC Medicaid Clinical Coverage Policy web page. 

Summary of Updates

In subsection 3.2.1.d Specific criteria covered by both Medicaid and NCHC, added
“doctors of podiatric medicine (DPMs)” so podiatrists may issue certain orthotic and prosthetic devices when the devices are part of the beneficiary’s current care and treatment.

In subsection 6.1.c Provider Qualifications and Occupational Licensing Entity Regulations, added “DPMs” so podiatrists may provide devices as indicated in the Required Provider Certification column of Attachment B of policy, when enrolled with NC Medicaid.

In subsection 6.2 Provider Qualifications, added “DPMs” so the sentence now reads, “In addition to the provisions in Section 6.0, provider(s) other than MDs, DOs, DPMs, PAs and NPs shall fulfill all the following conditions to qualify for participation with Medicaid and NCHC as orthotics and prosthetics supplier(s).”

In Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, added “DPM indicates Doctor of Podiatric Medicine.”

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, section I. Lower Limb Prostheses, added coverage, lifetime expectancies and rendering provider credentials for HCPCS code K1022 (addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type).

The Lifetime Expectancy and Quantity Limitations column of Attachment B was updated for clarity throughout.

Updated Attachment A, Section F. Place of Service to align with NCTracks and most recent version of DME policy 5A-2.

Additional Resources

The full text of Clinical Coverage Policy 5B, Orthotics and Prosthetics is available at NC Medicaid’s Orthotics and Prosthetics web page

Contact

NC Medicaid Contact Center, 888-245-0179

 

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