NC Medicaid 5B Orthotics and Prosthetics clinical policy update 45-day public comment and S1040 cranial remolding orthosis criteria

On 2/12/2024, the Policy Development team posted the proposed NC Medicaid 5B Orthotics and Prosthetics policy update for a 45-day public comment period.  The policy will stay posted until 3/28/2024 to receive comments. 

In the highlighted part of Section 8.0, you will find a summary of the proposed updates. 

The Cranial Remolding Orthosis criteria update starts on page 7 of the policy. 

NCAAOP members are strongly encourage to add comments and corrections that are needed. 

The Lifetime Expectancies and Quantity Limitations of the S1040 HCPCS code will be changed to “0-18 months” instead of “0-12 months” and the following updates will be made:

• 2024 CMS updated HCPCS codes (A6531 revised and replaced with A6552; A6532 revised and replaced with A6554; A6545 revised and replaced with A6583; K1022 end-dated and replaced with L5926). 

 
The 45-day public comment page for proposed policies can be found at the following link:  https://medicaid.ncdhhs.gov/meetings-notices/proposed-medicaid-policies
 
Submit comments for policies listed below open for public comment by emailing: [email protected]

A provider can still request prior approval (PA) for a child or an adult Medicaid beneficiary for any unlisted code (nationally recognized code that is not listed in the NC Medicaid 5B O&P policy or on the NC Medicaid O&P fee schedule) when the item is prescribed by the doctor and other documentation is included to show medical necessity, such as a letter of medical necessity or visit notes. 

Please also include a signed CMN/PA form and a quote or invoice for the unlisted item on the PA.   

A6531, A6532 and A6545 have been revised by CMS to use with a surgical dressing so they will need to be replaced these HCPCS codes with A6552, A6554 and A6583.
K1022 has been end-dated by CMS so they will need to be replaced by this HCPCS code with the new L5926 code.  

The NCTracks system has already been updated with the pricing for the new codes (A6552, A6554, A6583, and L5926) with an effective date of 1/1/2024 even though the policy and fee schedule has not been updated yet.  Use the new codes when submitting PA or billing NC Medicaid. 

• A6552 is the new code to replace A6531 which has been revised by CMS.
• A6554 is the new code to replace A6532 which has been revised by CMS.
• A6583 is the new code to replace A6545 which has been revised by CMS.
• L5926 is the new code to replace K1022 which was end-dated by CMS.

With the upcoming amended 5B policy coming soon, the following are the only items of the NC Medicaid 5B Orthotics and Prosthetics policy that are affected by the 2024 CMS annual HCPCS code update. 

These are the only HCPCS code changes that will also be reflected on the O&P fee schedule once the new policy is posted.