Section 418.10214. Orthotic and prosthetic equipment.

(1) A copy of a prescription by 1 of the following is required for prosthetic and orthotic equipment:

(a)   A doctor of medicine.

(b)   A doctor of osteopathic medicine and surgery.

(c)   A doctor of chiropractic.

(d)  A doctor of podiatric medicine and surgery.

(2)  Orthotic equipment may be any of the following:

(a)   Custom-fit.

(b)   Custom-fabricated.

(c)   Non-custom supply that is prefabricated or off-the-shelf.

(3)   A non-custom supply shall be billed using procedure code 99070, appropriate L-codes or A4570 for a prefabricated orthosis.

(4)    An orthotist or prosthetist that is certified by the American board for certification in orthotics and prosthetics shall bill orthosis and prostheses that are custom-fabricated, molded to the patient, or molded to a patient model. Licensed physical and licensed occupational therapists may bill orthoses using L-codes within their discipline's scope of practice. In addition, a doctor of podiatric medicine and surgery may bill for a custom fabricated or custom-fit, or molded patient model foot orthosis using procedure codes L3000-

L3649.

(5)   If a licensed occupational therapist or licensed physical therapist constructs an extremity orthosis that is not adequately described by another L-code, then the therapist shall bill the service using procedure code L3999.The carrier shall reimburse this code as a "by report" or

"BR" procedure. The provider shall include the following information with the bill:

(a)   A description of the orthosis.

(b)   The time taken to construct or modify the orthosis.

(c)   The charge for materials, if applicable.

(6)   L-code procedures shall include fitting and adjustment of the equipment.

(7)   The health care services division shall provide the maximum allowable payments for L- code procedures separate from these rules on the agency’s website, www.michigan.gov/wca. If an L-code procedure does not have an assigned maximum allowable payment, then the procedure shall be by report, "BR."

(8)      A provider may not bill more than 4 dynamic prosthetic test sockets without documentation of medical necessity. If the physician's prescription or medical condition requires utilization of more than 4 test sockets, then a report shall be included with the bill that outlines a detailed description of the medical condition or circumstances that necessitate each additional test socket provided.

History: 2000 AACS; 2004 AACS; 2009 AACS; 2010 AACS; 2014 AACS.