Prosthetics and orthotics must be billed on a CMS-1500/ANSI 837P. Block 24b - Place of Service
The place of service (POS) should represent where the item is being used, not where it is dispensed.
Block 24a - From and To Date(s) of Service
Enter the month, day and year for each procedure, service or supply. Block 24d - Codes and Modifiers
Prosthetics and orthotics must be billed using the most appropriate HCPCS code and applicable modifiers in effect for the date of service.
Codes and modifiers must be billed in accordance with the following:
Durable Medical Equipment Medicare Administrative Contractor (DME MAC*) for Jurisdiction C guidelines which includes, but are not limited to the following:
• DMEPOS Supplier Manual and Revisions • DME MAC for Jurisdiction C Insider
• Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC**) Product Classification Lists
• Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC**) Coding Bulletins *This document is located on the CIGNA Government Services Web site at
http://www.cignagovernmentservices.com
**This document is located on the Palmetto Government Benefits Administrator’s Web site at http://www.pgba.com.
General Billing Guidelines
Warranties-Supplier must honor all product warranties, express and implied, under applicable state law. Maintenance and/or service charges for prosthetics and orthotics covered under a manufacturer or supplier's warranty are not billable unless such charges are excluded from the warranty.
Mileage is not separately reimbursed or billable.
Unlisted, miscellaneous, non-specific, and Not Otherwise Classified (NOC) codes (e.g. L0999, L1499, L2999, L3649, L3999, L5999, L7499, L8039, L8239, L8499, L8699, L9900) should only be used when a more specific CPT® or HCPCS code is not available or appropriate.
Prosthetics or orthotics billed with an unlisted, miscellaneous, non-specific, and Not Otherwise Classified (NOC) codes must be billed with the name of the manufacturer, product name, product number, and quantity provided.
Codes without a published Medicare fee - BlueCross BlueShield of Tennessee reserves the right to request the name of the manufacturer, product name, product number, and quantity provided. Prosthetics
Repairs, Adjustments, and Replacements
• An adjustment is any modification to the prosthesis due to change in the patient's condition or to improve the function of the prosthesis.
• A repair is a restoration of the prosthesis to correct problems to due to wear or damage.
• A replacement is the removal and substitution of a component of a prosthesis that has a HCPCS definition.
The following items are included in the reimbursement for a prosthesis and, therefore, are not separately billable:
• Evaluation of the residual limb and gait • Fitting of the prosthesis
• Cost of base component parts and labor contained in HCPCS base codes • Repairs due to normal wear or tear within 90 days of delivery
• Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component and for 90 days from the date of delivery when the adjustments are not necessitated by changes in the residual limb or the patient's functional abilities
Routine periodic servicing, such as testing, cleaning, and checking of the prosthesis is not separately billable.
Repairs to prosthesis are billable when necessary to make the prosthesis functional. If the expense for repairs exceeds the estimated expense of purchasing another entire prosthesis, no payment can be made for the amount of the excess. Maintenance, which may be necessitated by manufacturer's recommendations or the construction of the prosthesis and must be performed by the prosthetist, is billable as a repair.
Reimbursement for reasonable and necessary parts and labor, which are not covered under any manufacturer or supplier warranty, may be allowed. Parts should be billed using the most
appropriate HCPCS code and the "RP" modifier in the modifier 1 field. Labor should be billed using the most appropriate HCPCS code (e.g. L7500, L7520) with the "RP" modifier in the modifier 1 field.
Billable parts and labor must be billed on the same claim form.
Orthotics
Evaluation of the patient, measurement and/or casting, and fitting of the orthosis are included in the allowance for the orthosis and are not separately billable. There is no separate payment for these services.
Repairs to an orthotic due to wear or to accidental damage are billable when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier's record. If the expense for the repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.
Replacement of a complete orthotic or component of an orthotic due to loss, significant change in the Member’s condition, irreparable wear, or irreparable accidental damage is billable if the device is still Medically Necessary. The reason for the replacement must be documented in the supplier's record.
The allowance for the labor involved in replacing an orthotic component that is coded with a specific L code is included in the allowance for that component and is not separately billable.
The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous code L4210 is separately billable in addition to the allowance for that component. Billable orthotic components and labor must be billed on the same claim form.
5. Reimbursement Guidelines for Immune Globulins, Vaccines, and Toxoids
BlueCross BlueShield of Tennessee shall reimburse providers for eligible immune globulins, vaccines and toxoids based on a percentage of Average Wholesale Price (AWP) according to one of the following methods:A. The AWP based on the National Drug Code (NDC) for the specific drug billed. Or
A. For a single-source drug, the AWP equals the AWP of the single product.
B. For a multi-source drug, the AWP is equal to the lesser of the median AWP of all of the generic forms of the drug or the lowest brand name product AWP.
BlueCross BlueShield of Tennessee reserves the right to select the method used to calculate AWP and the source for AWP for immune globulins, vaccines and toxoids.
To determine eligibility and reimbursement for a immune globulin, vaccine or toxoid, BlueCross
BlueShield of Tennessee reserves the right to request the name of the drug, National Drug Code (NDC), dosage and number of units for items billed with an unlisted, miscellaneous, not otherwise classified CPT® or HCPCS code.
The percentage of AWP that will be reimbursed for immune globulins, vaccines and toxoids will be 100% with the exception of Provider agreements under the BlueCross BlueShield of Tennessee Medicare Based Professional Maximum Allowable Fee Schedule. For Provider agreements under the BlueCross BlueShield of Tennessee Medicare Based Professional Maximum Allowable Fee Schedule, the
percentage of AWP will be reimbursed at 102.5%.
Services included in the State of Tennessee Bureau of TennCare’s Pharmacy Benefits Manager (PBM) Program are not billable to or reimbursable by the BlueCross BlueShield of Tennessee BlueCare or TennCareSelect Networks. Refer to the PBM Program billing guidelines in section V.O.
Note: Refer to the guidelines in the “Vaccines for Children (VFC) Program for BlueCare Members Age 18 and Under” section for services eligible for reimbursement under this program.