Tenn. Comp. R. & Regs. 0800-02-18-.11 - ORTHOTICS AND PROSTHETICS GUIDELINES
(1) Orthotics
and prosthetics, not supplied under 0800-02-18-.07, should be coded according
to the Healthcare Common Procedures Coding System (HCPCS). Maximum
reimbursement is the lesser of the billed charge or the amount listed in the
rate tables. If the orthotic or prosthetic is not included in the rate tables
or if the original manufacturer's invoice cost exceeds the amount listed in the
rate tables at the time of delivery, the payment for orthotics and prosthetics
shall be the higher of the original manufacturer's invoice costs or 115% of the
amount listed in the fee schedule. Charges for these items are in addition to,
and shall be billed separately from, all other facility and professional
service fees. Supplies and equipment should be billed using CPT® code 99070
if appropriate codes are not available in the HCPCS, and the maximum
reimbursement shall be the usual and customary amount. Charges should be
submitted on the CMS-1500 form or its approved successor form.
(2) Fitting and customizing may be reimbursed
separately using CPT® code 97760, orthotics management and training initial
encounter each 15 minutes; CPT® code 97761, prosthetics training initial
encounter each 15 minutes; and CPT® code 97763, orthotics/prosthetics
management and training, subsequent encounter, each 15 minutes, as
appropriate.
(3) For the purpose of
reimbursements, hearing aids are considered under this section.
Notes
Authority: T.C.A. §§ 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).
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(1) Orthotics and prosthetics, not supplied under 0800-02-18-.07, should be coded according to the HCFA Common Procedures Coding System (HCPCS). Payment shall be 115% of Tennessee Medicare allowable amount. If the invoice costs exceed the Medicare payments amounts at the time of delivery, the payment for orthotics and prosthetics shall be the higher of invoice costs or 115% of the Tennessee Medicare allowable amount and coded using the HCPCS code. Charges for these items are in addition to, and shall be billed separately from all other facility and professional service fees. Supplies and equipment should be coded 99070 if appropriate codes are not available in the HCPCS and the maximum reimbursement shall be the usual and customary amount. Charges should be submitted on the HCFA 1500 form or its approved successor form.
(2) Fitting and customizing codes may be reimbursed separately according to Medicare guidelines.
(3) For the purpose of reimbursements, hearing aids are considered under this section.
Notes
Authority: T.C.A. §§ 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).