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Orthotic and Prosthetic Providers


General

Orthotic services include the custom design, fabrication and fitting of braces and supports for the treatment of musculoskeletal conditions. These conditions may range from short-term sports related injuries to long-term progressive neurological diseases. Prosthetic services include the custom design, fabrication and fitting of artificial appliances used to replace or restore human body parts or organs in order to regain the loss functionality of the missing part.

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Billing Requirements

  • Specific and inclusive codes, when available, to prevent over utilization of miscellaneous codes (e.g., L2999) and inappropriate “unbundling.”
  • Orthotics and Prosthetics are not reusable and should be submitted with the NU modifier.
  • Repairs for Orthotics and Prosthetics should be billed using appropriate codes with documentation of what repairs were performed.
    • L4205 for repair of orthotic device, labor component; per 15 minutes
    • L7520 for repair of prosthetic device, labor component, per 15 minutes
  • Repairs should not exceed the cost for a new device. If the expense for repairs exceeds the estimated expense of purchasing for the remaining period of medical need, no payment can be made for the amount in excess.
  • Repair or replacement of a purchased item may occur when the item is irreparably damaged or replacement is needed due to growth of a child or due to a change in the member’s condition.
  • Replacement or repair of an item that has been misused or abused by the member or member’s caregiver will be the responsibility of the member.
  • For unlisted codes, include an itemized description with an invoice showing the MSRP for each unlisted code.

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Reimbursement

Reimbursement for the following is included in the allowance for the covered orthotic or prosthetic device:

  • Professional services for preparation and fitting
  • Orthotic and prosthetic management (97760-97762)
  • Hospital visits rendered in conjunction with an amputation procedure
  • Cement, cleansers and other supplies used in "initial" implantation or insertion or application
  • Travel time

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Non-reimbursable items include, but are not limited to:

  • Fitting or dispensing fees
  • Sales tax (S9999)
  • Items that do not require a physician’s written order or prescription are generally non-reimbursable
  • Implantable prosthetics (L8600-L8699), which are included in the facility or physician reimbursement

Note: Certain over-the-counter, non-durable items (e.g., arm slings, ace bandages, splints, foam cervical collars, etc.) are not eligible for payment because they do not fit within the definition of durable medical equipment, prosthetics or therapeutic orthotics.

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10/29/2010
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

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