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

Tenn. Comp. R. & Regs. 0800-02-18-.11

Public necessity rule filed June 5, 2005; effective through November 27, 2005. Public necessity rule filed November 16, 2005; effective through April 30, 2006. Original rule filed February 3, 2006; effective April 19, 2006. Amendment filed December 20, 2007; effective March 4, 2008. Amendment filed June 12, 2009; effective August 26, 2009. Amendments filed November 27, 2017; effective February 25, 2018. Amendments filed June 12, 2019; effective September 10, 2019. Administrative changes made to this chapter on September 10, 2019; "Tennessee Workers' Compensation Act" or "Act" references were changed to "Tennessee Workers' Compensation Law" or "Law." Amendments filed June 27, 2023; effective 9/25/2023.

Authority: T.C.A. §§ 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).