R 418.10214 Orthotic and prosthetic equipment.

Rule 214. (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 an unlisted or “not otherwise specified” L-code.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.