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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

April 2018

Payment Policy Updates: DME and Orthotic and Prosthetic Devices


Harvard Pilgrim regularly reviews coding practices to ensure that the care delivered to our members is represented as completely and accurately as possible.

As a result, we are making changes to the coding requirements detailed in our commercial Durable Medical Equipment (DME) and Orthotic and Prosthetic Devices payment policies, such as requiring modifiers to be billed alongside certain procedure codes for lower limb prosthetics, tape, and other DME. The new coding requirements, which will be effective for dates of service beginning June 1, 2018, are designed to provide more specificity and clarity to Harvard Pilgrim, so that we have the information necessary to provide appropriate reimbursement.

Please note that in addition to the added requirements detailed in this article, DME and orthotics and prosthetic devices must still be reported with the appropriate primary modifier — NU (purchase of new equipment), MS (maintenance and servicing), or RR (rental) — as applicable, for proper payment.

Procedure codes that will require functional modifiers

With the updates to the DME Payment Policy, Harvard Pilgrim will require the following HCPCS procedure codes for lower limb prosthetics to be reported with the appropriate functional modifier (K0, K1, K2, K3, or K4) in order for the provider to receive reimbursement: L5930, L5961, L5969-L5976, L5978-L5982, L5987, L5610, L5613, L5614, L5722-L5780, L5822-L5840, L5848, L5856, L5857, L5859, L5611, L5616, L5710-L5718, L5810-L5818.

Modifiers AU, AV, and AW

When billing non-waterproof or waterproof tape (HCPCS codes A4450 and A4452), providers will be required to append the appropriate modifier from A1-A9 to specify the number of wounds being dressed, and also to append modifier AU, AV, or AW to indicate if the item was furnished in conjunction with a urological, ostomy, or tracheostomy supply; prosthetic device, prosthetic or orthotic; or surgical dressing.

Appending modifier AU or AV will also be required when billing HCPCS code A5120 for skin barrier, wipes, or swabs.

RT and LT modifiers

As of June 1, Harvard Pilgrim will only reimburse HCPCS codes A5500-A5513 (Therapeutic shoes/inserts/modifications for diabetics only) when they are billed with the RT or LT modifier to indicate the right or left side of the body.

Providers will also be required to append the LT or RT modifier when billing for orthotics and prosthetics. Other changes regarding orthotics and prosthetics include:

  • Repairs or adjustments made to an orthotic device (HCPCS code L4205) at the time of delivery, or within 90 days of the time of delivery, will not be reimbursed separately because they are included in the allowance for the orthotic device.

  • HCPCS code L9900 (orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code) will not be separately reimbursed when billed in conjunction with a microprocessor-controlled knee prosthesis (L5856-L5859).

For more information, refer to Harvard Pilgrim’s updated Durable Medical Equipment Payment Policy and Orthotic and Prosthetic Devices Payment Policy.

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