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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.7 Orthotic and Prosthetic Services (CCP) : 2.7.5 Prosthetic Services

2.7.5
2.7.5.1
External prostheses are a benefit of Texas Medicaid when provided by a licensed prosthetist or licensed prosthetist/orthotist through CCP for clients who are birth through 20 years of age.
The following prostheses and related services may be reimbursed when medical necessity criteria are met:
Prosthetic training by a physical or occupational therapist for a lower limb prosthesis or an upper extremity prosthesis is a benefit for clients who have not worn one previously or for a prolonged period or who are receiving a different type.
Refer to:
Subsection 2.10, “Therapy Services (CCP)” in this handbook for more information on physical and occupational therapy services.
To be considered for reimbursement, prostheses must be dispensed, fabricated, or modified by a licensed prosthetist or licensed prosthetist/orthotist enrolled with Medicare and CCP.
The date of service for a custom-made or custom-fitted prosthesis is the date the supplier places an order for the equipment and incurs a liability for the equipment. The custom-made or custom-fitted prosthesis will be eligible for reimbursement as long as the service is provided during a month the client is eligible for Medicaid.
The following items and services are included in the reimbursement for a prosthetic device and not reimbursed separately:
Adjustments or modifications 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 client’s functional ability
In general, base codes do not represent a complete device. To include the additional components necessary for a complete device, providers may bill additional components with a code that is used in addition to a base code. Addition codes may also be used to indicate modifications to a device. The values assigned to the additional codes do not represent the actual value of the component or modification, but only the difference between the total value and the value of the base code. As a result, reimbursement of an addition does not involve subtraction of any amounts from the base code allowance.
2.7.5.1.1 Noncovered Prosthetic Services
Prosthetic devices prescribed by a chiropractor are not a benefit of Texas Medicaid.
A vacuum-assisted socket system (procedure code L5781 or L5782), which is a specialized vacuum pump, is considered experimental and investigational, and is not a benefit of Texas Medicaid.
Myoelectric hand prostheses for conditions other than the absence of forearm(s) and hand(s) are considered experimental and investigational and are not a benefit of Texas Medicaid.
A prosthetic device customized with enhanced features is not considered medically necessary if ADLs can be met with a standard prosthetic device.
Accessories that are not required for the effective use of a prosthetic device are not considered medically necessary.

Texas Medicaid & Healthcare Partnership
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