Chapter 100 Children's Specialty Clinics - Alabama Medicaid Agency

100100 Children’s Specialty ClinicsChildren's Specialty Clinic Services are specialty-oriented services providedby an interdisciplinary team to children who are eligible for EPSDT servicesand who experience developmental problems. Children's Specialty ClinicServices include preventive, diagnostic, therapeutic, rehabilitative, or palliativeservices provided in a clinic setting that is not part of a hospital, but isoperated to provide medical care on an outpatient basis to children withspecial health care needs.Clinic services include the following outpatient services:• Services furnished at the clinic by or under the direction of a physician ordentist• Services furnished outside the clinic, by clinic personnel under thedirection of a physician, to an eligible individual who does not reside in apermanent dwelling or does not have a fixed home or mailing addressClinics include:ArthritisAugmentative CommunicationBehavior AssessmentBiochemical GeneticsCerebral PalsyChild DevelopmentCleft PalateCystic FibrosisDentistryEyeFeeding (OT)GeneticsHearingHearing AidHearing AssessmentHemophiliaLimb DeficiencyMultiple DisabilitiesNeurologyNeuromotorNeurosurgeryOrthopedicPediatric CommunicationPediatric EvaluationPediatric OrthopedicPediatric SurgeryPsycho-educationScoliosisSeating, Positioning & MobilitySeizureSpeech PathologySpina BifidaTeen TransitionUrologyEligible persons may receive Children's Specialty Clinic Services throughproviders who contract with Medicaid to provide services to children eligiblefor EPSDT services.The policy provisions for clinic providers can be found in the AlabamaMedicaid Agency Administrative Code, Chapter 61.July 2013 100-1

Children’s Specialty Clinics100.1 EnrollmentHP enrolls children’s specialty clinics and issues provider contracts toapplicants who meet the licensure and/or certification requirements of thestate of Alabama, the Code of Federal Regulations, the Alabama MedicaidAdministrative Code, and the Alabama Medicaid Provider Manual.In order to meet federal enrollment criteria, all Children’s RehabilitationServices providers must have a NPI with ADRS/CRS identified as payee.Sparks Rehab Center shall submit claims for clinic services to Medicaid underthe physician’s clinic NPI or (if no physician is present) under the clinic NPI.Refer to Chapter 2, Becoming a Medicaid Provider, for general enrollmentinstructions and information. Failure to provide accurate and truthfulinformation or intentional misrepresentation might result in action ranging fromdenial of application to permanent exclusion.National Provider Identifier, Type, and SpecialtyA provider who contracts with Alabama Medicaid as a clinic is added to theMedicaid system with the National Provider Identifiers provided at the timeapplication is made. Appropriate provider specialty codes are assigned toenable the provider to submit requests and receive reimbursements for clinicrelatedclaims.NOTE:The 10-digit NPI is required when filing a claim.Clinics are assigned a provider type of 57(Clinics). Valid specialties for clinicsinclude the following:• Children’s Rehabilitation Service (015)• EPSDT (560)• Hemophilia (990)• Orthodontia (273)• Radiology Clinics (995)• Sparks Rehab Center (850)• Optometry (180)• United Cerebral Palsy (UCP) (840)100-2 July 2013

Children’s Specialty ClinicsChildren’s Specialty Clinic TeamsThe clinic teams are usually comprised of physicians, registered nurses,social workers, therapists, audiologists, and rehabilitation assistants, clericaland/or support personnel. Clinic composition may vary depending on the typeof clinic; however, clinic team protocol must be furnished to and approved byMedicaid. Clinic team protocol will be updated on an as-needed basis, butannually at a minimum. The team will establish a written patient care plan.The case management team then implements this plan.100.2.1 Covered ServicesChildren's Specialty Clinic Services do not include services rendered underother Medicaid programs.Children's Specialty Clinic Services are covered when provided by aMedicaid-enrolled children's specialty clinic provider.Types of covered services provided in clinics include:• Diagnosis of medical condition• Completion of durable medical equipment assessments• Development of a patient care plan• Therapy (physical, speech/language, occupational)• Patient/parent education• Audiology services• Physician services• Psychological services• Multidisciplinary evaluations• Orthotic services• Prosthetic services• Optometrical services• Dental services• Nutrition services• Prescriptions for services or medications• Nursing and social work services• Case management• Hearing aid services• Vision servicesFor details of dental services covered in children’s specialty clinics see RuleNo. 560-X-15.06 (3) of the Alabama Medicaid Administrative Code.A patient care plan is required for each child and a service coordinator isresponsible for arranging specialty and needed social services for the family.100.2.2 ReimbursementChildren's Specialty Clinics will be reimbursed by an encounter rate. For moreinformation regarding reimbursement for governmental providers, please referto the “Children’s Specialty Clinic Services Reimbursement Manual.”Governmental providers of Children's Specialty Clinic Services will bereimbursed by an encounter rate based on reasonable allowable cost, asdefined by OMB Circular A-87, established by the Medicaid Agency based oncompletion of the required cost report documentation.100-4 July 2013

Children’s Specialty Clinics 100Non-governmental providers will be paid their usual and customary chargenot to exceed the maximum allowable rate established by Medicaid.Claims may be submitted for reimbursement for only one clinic visit per dateof service per recipient, except in the case of dental visits. A dental encountermay be billed in conjunction with only one other clinic visit for the same dateof service for the same recipient.NOTE:Procedure code D8080 is limited to once per year with prior authorization.Procedure code D8680 is limited to once every two years with priorauthorization.Procedure code D9310 is limited to once per recipient per lifetime withprior authorization.100.2.3 EncountersCovered encounters are face-to-face clinic contacts during which a healthprofessional team provides medical services to a patient. They are identifiedbased on the data from clinic sign-in sheets and the individual medicalrecords.The definition of a health professional depends upon the type of clinic. To becounted as a physician encounter, the highest level health professional mustbe a physician.Examples of physician encounters include the following types of visits, all ofwhich are attended by a physician:• Arthritis• Cerebral palsy• Cleft palate• Clubfoot• Craniofacial• Cystic fibrosis• Eye• Genetics• Hearing• Hemophilia• Limb Deficiency• Multi-specialty• Neurology• Neuromotor• Neurosurgical• Orthopedic• Pediatric Evaluation• Pediatric surgery• Scoliosis• Seizure• Spina bifida• Teen Transition• Urology clinicsTo be counted as a non-physician encounter, the health professional(s) mustbe qualified to perform the service, and although a physician is not present,the service must be provided under the direction of a physician. Examples ofnon-physician clinics include augmentative communication, feeding (OT),hearing aid orientation/maintenance, infant/toddler functional evaluation, andseating.Multiple contacts with the same health professional(s) that take place on thesame day at a single location constitute a single encounter. Services incidentto an encounter, or subsequent to the clinic encounter, such as socialJuly 2013 100-5

Children’s Specialty Clinicsservices, case management, nursing, writing of prescriptions, clerical,therapy, and pre-certification evaluations are inclusive in the encounter andshould not be billed separately.For example, if a client comes to the limb deficiency clinic, the minimumstaffing standards must be met in order for the contact to be counted as anencounter. In this case, the orthopedist, physical therapist, and social workermust be present. Their face-to-face contact with the client constitutes anencounter. Subsequent visits for purposes of physical therapy only by thetherapist do not constitute an encounter since these costs are included in theencounter rate that is billed only when the minimum staffing standards for aclinic are met.100.2.4 Maintenance of RecordsThe provider must make available to the Alabama Medicaid Agency at nocharge all information regarding claims for services provided to eligiblerecipients. The provider will permit access to all records and facilities for thepurpose of claims audit, program monitoring, and utilization review by dulyauthorized representatives of federal and state agencies. The providermaintains complete and accurate fiscal records that fully disclose the extentand cost of services.The provider maintains documentation of Medicaid clients' signatures. Thesesignatures may be entered on a sign-in log, service receipt, or any otherrecord that can be used to indicate the clients' signatures and dates ofservice.The provider maintains all records for a period of at least three years plus thecurrent fiscal year. If audit, litigation, or other legal action by or on behalf ofthe state or federal government has begun but is not completed at the end ofthe three-year period, the provider retains the records until the legal action isresolved. The provider must keep records in a format that facilitates theestablishment of a complete audit trail in the event the items are audited.100.3 Prior Authorization and Referral RequirementsClinic procedure codes generally do not require prior authorization; however,orthodontia services always require prior authorization. Any servicewarranted outside of these codes must have prior authorization. Refer toChapter 4, Obtaining Prior Authorization, for general guidelines.When filing claims for recipients enrolled in the Patient 1 st Program, refer toChapter 39, Patient 1 st , to determine whether your services require a referralfrom the Primary Medical Provider (PMP).‣Electronicclaimssubmission cansave you timeand money.The systemalerts you tocommon errorsand allows youto correct andresubmit claimsonline.100.4 Cost Sharing (Copayment)Copayment does not apply to services provided by Children’s SpecialtyClinics.100.5 Completing the Claim FormTo enhance the effectiveness and efficiency of Medicaid processing,providers should bill Medicaid claims electronically.Children’s specialty clinics that bill Medicaid claims electronically receive thefollowing benefits:• Quicker claim processing turnaround• Immediate claim correction• Online adjustment functions100-6 July 2013

Children’s Specialty Clinics 100• Enhanced access to eligibility informationRefer to Appendix B, Electronic Media Claims Guidelines, for moreinformation about electronic filing.NOTE:When filing a claim on paper, a CMS-1500 claim form is required.Medicare-related claims must be filed using the MedicalMedicaid/Medicare Related Claim Form.This section describes program-specific claims information. Refer to Chapter5, Filing Claims, for general claims filing information and instructions.100.5.1 Time Limit for Filing ClaimsMedicaid requires all claims for clinics to be filed within one year from the dateof service. Refer to Section 5.1.5, Filing Limits and Approved Exceptions, formore information regarding timely filing limits and exceptions.100.5.2 Diagnosis CodesThe International Classification of Diseases - 9th Revision - ClinicalModification (ICD-9-CM) manual lists required diagnosis codes. Thesemanuals may be obtained by contacting the American Medical Association,P.O. Box 10950, Chicago, IL 60610.NOTE:ICD-9 diagnosis codes must be listed to the highest number of digitspossible (3, 4, or 5 digits). Do not use decimal points in the diagnosiscode field.100.5.3 Procedure Codes and ModifiersMedicaid uses the Healthcare Common Procedure Coding System (HCPCS).HCPCS is composed of the following:• American Medical Association’s Current Procedural Terminology (CPT)• Nationally assigned codes developed for Medicare• Locally assigned codes issued by Medicaid. Effective for dates of serviceon or after 01/01/2004, use national codes.The CPT manual lists most procedure codes required by Medicaid. Thismanual may be obtained by contacting the Order Department, AmericanMedical Association, 515 North State Street, Chicago, IL 60610-9986. The(837) Professional, Institutional and Dental electronic claims and the paperclaim have been modified to accept up to four Procedure Code Modifiers.July 2013 100-7

Children’s Specialty ClinicsThe following procedure codes have been approved for billing by children’sspecialty clinics.Clinic ServicesProcedureCodeWho Can BillDescription99203-HT CRS Neurology, Neuromotor, Cerebral Palsy, Cleft Palate,Hemophilia, Limb Deficiency, PediatricAssessment,Pediatric Orthopedic Specialty, Seizure,and Spina Bifida.99204-HTCRS(New Patients) Arthritis, Genetics, and Limb Deficiency.99213-HT CRS Regular Clinic, which includes Neurology, LimbDeficiency, Pediatric Assessment, PediatricOrthopedic Specialty Clinic, Cleft Palate Clinic,Cerebral Palsy, Hemophilia, Seizure, Spina Bifida, andNeuromotor Clinic99214-HT CRS, Sparks Specialty Clinic, which includes PediatricCommunication Clinic, Cystic Fibrosis Clinic, andGenetics Clinic99205-HT CRS, Sparks Interdisciplinary Team Clinic (new patient) – limited toonly once per physician per recipient lifetime CysticFibrosis Clinic, and Pediatric Evaluation.99215-HT CRS, Sparks Interdisciplinary Team Clinic (established patient) –repeat clinic visitsInterdisciplinary Team Clinics include AugmentativeCommunication Technology Evaluation, BehaviorAssessment Clinic, Biochemical Genetics Clinic, CysticFibrosis Clinic, Feeding Clinic, Seating Clinic, PediatricEvaluation, and Teen Transition Clinic.CRS CLINIC TEAMSSPECIALTYCLINICMEDICAL STAFFPARA-MEDICALSTAFFSOCIAL andADMINISTRATIVESTAFFARTHRITIS CLINIC99212-HT*RHEUMATOLOGISTor IMMUNOLOGISTOphthalmologistOrthopedist*NURSE (BSN)*PHYSICALTHERAPISTOccupational TherapistRegistered Dietitian*LICENSED SOCIALWORKERSecretaryAUGMENTATIVECOMMUNICATION/TECHNOLOGYCLINICEvaluation99215-HTUnder the direction of aphysician*SPEECH/LANGUAGEPATHOLOGIST(CCC/SLP)*PHYSICALTHERAPIST*OCCUPATIONALTHERAPIST*REHABILIATIONTECHNOLOGYSPECIALIST*LICENSED SOCIALWORKERVocational RehabilitationCounselorSecretary*Denotes minimum staffing standards100-8 July 2013

CRS CLINIC TEAMSChildren’s Specialty Clinics 100SPECIALTYCLINICMEDICAL STAFFPARA-MEDICALSTAFFSOCIAL andADMINISTRATIVESTAFFCEREBRAL PALSYCLINIC99212-HTAlso known asNEURO-ORTHOCLINIC*ORTHOPEDISTor PEDIATRICNEUROLOGISTor NEUROLOGISTor PEDIATRICIANor PHYSICAL MEDICINE*NURSE (BSN)*PHYSICALTHERAPIST*REGISTEREDDIETITIANOccupational TherapistSpeech/LanguagePathologist(CCC/SLP)*LICENSED SOCIALWORKERSecretaryCLEFT PALATECLINIC99212-HT*PLASTIC SURGEON*ORTHODONTISTor DENTISTPediatrician GeneticistProsthodontistOtolaryngologistOral Surgeon*NURSE (BSN)*AUDIOLOGIST*SPEECH/LANGUAGEPATHOLOGIST(CCC/SLP)*REGISTEREDDIETITIANGeneticsCounselor/RN*LICENSED SOCIALWORKERMental Health CounselorSecretaryCYSTIC FIBROSISCLINIC99214-HT99205-HT or99215-HT*PULMONOLOGISTAllergist/ImmunologistGastroenterologist*NURSE (BSN)*REGISTEREDDIETITIANRespiratory TherapistPharmacistAudiologist*LICENSED SOCIALWORKERSecretaryEYE CLINIC99212-HT*OPHTHALOMOLOGISTor OPTOMETRIST*NURSE (BSN)OpticianOphthalmic Technician*LICENSED SOCIALWORKERSecretaryFEEDING CLINIC99215-HTUnder the direction of aphysician*REGISTEREDDIETITIAN*OCCUPATIONALTHERAPIST*SPEECH/LANGUAGEPATHOLOGIST(CCC/SLP)*NURSE (BSN)*LICENSED SOCIALWORKERSecretaryGENETICS CLINIC99204-HT or99214-HT*GENETICIST*NURSE (BSN)*GENETICS NURSE/COUNSELORRegistered Dietitian*LICENSED SOCIALWORKERSecretaryHEARING CLINIC99212-HT*OTOLARYNGOLOGIST*AUDIOLOGIST*NURSE (BSN)Speech/languagePathologist(CCC/SLP)Registered Dietitian*LICENSED SOCIALWORKERSecretaryHEARING AIDCLINIC andMaintenanceEvaluationUnder the direction of aphysician*AUDIOLOGISTNurse (BSN)Licensed Social WorkerSecretary99215-HTJuly 2013 100-9*Denotes minimum staffing standards

Children’s Specialty ClinicsCRS CLINIC TEAMSSPECIALTYCLINICMEDICAL STAFFPARA-MEDICALSTAFFSOCIAL andADMINISTRATIVESTAFFHEARINGASSESSMENTCLINIC99215-HTUnder the direction of aphysician*AUDIOLOGISTNurse (BSN)Licensed Social WorkerSecretaryHEMOPHILIACLINIC99203-HT or99213-HT*HEMATOLOGISTOrthopedistDentist*NURSE (BSN)*PHYSICALTHERAPISTRegistered Dietitian*LICENSED SOCIALWORKERSecretaryLIMB DEFICIENCYCLINIC99213-HT or99203-HT or99204-HT*PEDIATRICORTHOPEDICSURGEON and/orPHYSICIAL MEDICINE &REHABILITATIONPHYSICIAN*PHYSICALTHERAPIST*PROSTHETISTOccupational TherapistNurse (BSN)*LICENSED SOCIALWORKERSecretaryNEUROLOGYCLINICAlso known asPEDIATRICASSESSMENTPEDIATRICNEUROLOGY99203-HT or99213-HT*NEUROLOGIST*NURSE (BSN)*REGISTEREDDIETITIANPhysical TherapistOccupational TherapistSpeech/languagePathologist(CCC/SLP)*LICENSED SOCIALWORKERSecretaryNEUROMOTORCLINIC99212-HT or99203 or99213*PHYSICAL MEDICINENeurosurgeonOrthopedistUrologist*NURSE (BSN)*PHYSICALTHERAPIST*REGISTEREDDIETITIANOccupational TherapistNeuro-psychologistSpeech/languagePathologist(CCC/SLP)*LICENSED SOCIALWORKERRecreational TherapistSecretaryNEUROSURGERYCLINIC99212-HT*NEUROSURGEON*NURSE (BSN)Physical Therapist (oncall)Registered Dietitian*LICENSED SOCIALWORKERSecretaryORTHOPEDICCLINIC99212-HT*ORTHOPEDIST*NURSE (BSN)*PHYSICALTHERAPIST*REGISTEREDDIETITIANOccupational TherapistSpeech/languagePathologistDME Vendor Orthotist*LICENSED SOCIALWORKERSecretaryPEDIATRICEVALUATIONCLINIC*DEVELOPMENTALPEDIATRICIAN*NURSE (BSN)*PHYSICALTHERAPIST*LICENSED SOCIALWORKERSecretary100-10 July 2013

CRS CLINIC TEAMSChildren’s Specialty Clinics 100SPECIALTYCLINIC99205-HT or99215-HTMEDICAL STAFFPARA-MEDICALSTAFFRegistered DieticianOccupational TherapistSpeech/LanguagePathologistSOCIAL andADMINISTRATIVESTAFFPEDIATRICORTHOPEDICSPECIALTY CLINIC99203-HT or99213-HT*PEDIATRICORTHOPEDIST*NURSE (BSN)*PHYSICALTHERAPISTRegistered DietitianOccupational TherapistSpeech/LanguagePathologistDME VendorOrthotist*LICENSED SOCIALWORKERSecretaryPEDIATRICSURGERY CLINIC99212-HT*SURGEON*NURSE (BSN)*REGISTEREDDIETITIAN*LICENSED SOCIALWORKERSecretarySCOLIOSIS CLINIC99212-HT*ORTHOPEDIST*NURSE (BSN)*PHYSICALTHERAPISTRegistered Dietitian*LICENSED SOCIALWORKERSecretarySEATING,POSITIONING &MOBILITY CLINICUnder the direction of aphysician*PHYSICAL OROCCUPATIONALTHERAPIST*DME SPECIALISTLicensed Social WorkerSecretary99215-HTSEIZURE CLINIC99203-HT or99213-HT*NEUROLOGIST*NURSE (BSN)*REGISTEREDDIETITIANPharmacist*LICENSED SOCIALWORKERSecretarySPEECHPATHOLOGYCLINICUnder the direction of aphysician*SPEECH/LANGUAGEPATHOLOGISTAudiologistLicensed Social WorkerAdministrative SupportAssistant99203-HT or99213-HTSPINA BIFIDACLINIC99212-HTAlso known as:MULTI-SPECIALTYCLINIC*ORTHOPEDISTor NEUROSURGEONor UROLOGIST*NURSE (BSN)*PHYSICALTHERAPIST*REGISTEREDDIETITIANOccupational Therapist*LICENSED SOCIALWORKERSecretary*Denotes minimum staffing standardsJuly 2013 100-11

Children’s Specialty ClinicsCRS CLINIC TEAMSSPECIALTYCLINICMEDICAL STAFFPARA-MEDICALSTAFFSOCIAL andADMINISTRATIVESTAFFAdded: ONE ORMORE…ondiagnosis/need)TEEN TRANSITIONCLINIC99215-HT*PHYSICAL MEDICINEor ADOLESCENTMEDICINESPECIALISTor PEDIATRICIANONE OR MORE OFTHE FOLLOWING(optional):NURSE, PHYSICALTHERAPIST,OCCUPATIONALTHERAPIST,AUDIOLOGIST,NUTRITIONIST,SPEECH-LANGUAGEPATHOLOGIST orYOUTHCONSULTANT/ADVOCATE (based ondiagnosis/need)*TWO OF THEFOLLOWING:REHABILITATIONTECHNOLOGYSPECIALIST orVOCATIONALASSESSMENTSPECIALIST orINDEPENDENT LIVINGSPECIALIST*LICENSED SOCIALWORKERVocational RehabilitationCounselorRecreational TherapistSecretaryUROLOGY CLINIC *UROLOGIST99212-HT*Denotes minimum staffing standards*NURSE (BSN)Registered Dietitian*LICENSED SOCIALWORKERSecretary100-12 July 2013

Children’s Specialty Clinics 100NOTE:Claims for Radiology codes 70010 – 79999 must be filed separately fromclaims for all other services.Non-Clinic ServicesChildren’s Specialty Clinics also provide, or arrange provision of, non-clinicservices. The following procedure codes shall be utilized and will bereimbursed on a fee-for-service basis.Procedure Code Who Can Bill Description70010-79999 CRS RadiologyJ7188J7189J7190J7191J7192CRSInjection, Von Willebrand factor complex, per i.u.Factor ViiA, per 1mcg.Factor viii (antihemophilic factor, human), per i.u.Factor viii (antihemophilic factor, porcine), per i.u.Factor viii (antihemophilic factor, recombinant), peri.u.J7197J7198J7199J7193J7194J7195CRSCRSAntithrombin iii (human), per i.u.Anti-inhibitor, per i.u.Hemophilia clotting factor, not otherwise classifiedFactor ix (antihemophilic factor, purified, nonrecombinant)Factor ix, complex, per i.u.Factor ix (antihemophilic factor, recombinant), peri.u.D8080 CRS Comprehensive Orthodontic Treatment of theAdolescent Dentition (requires prior authorization)D8680 CRS Orthodontic Retention (removal of appliances,construction, and placement of retainer(s))(requires prior authorization)D9310 CRS ConsultationL3650 CRS Shoulder orthosis (SO), figure of “8” designabduction restrainerL3660 CRS SO, figure of “8” design abduction restrainer,canvas and webbingL3670 CRS SO, acromio/clavicular (canvas and webbing type)L3700 CRS Elbow orthoses (EO), elastic with staysL3710 CRS EO, elastic with metal jointsL3720 CRS EO, double upright with forearm/arm cuffs, freemotionL3730 CRS EO, double upright with forearm/arm/cuffs,extension/flexion assistL3740 CRS EO, double upright with forearm/arm cuffs,adjustable position lock with active controlL3800 CRS Wrist-hand-finger-orthoses (WHFO), shortopponens, no attachmentsL3805 CRS WHFO, long opponens, no attachmentL3810 CRS WHFO, addition to short and long opponens,thumb abduction (“C”) barL3815 CRS WHFO, addition to short and long opponens,second M.P. abduction assistL3820 CRS WHFO, addition to short and long opponens, IPextension assist, with M.P. extension stopL3825 CRS WHFO, addition to short and long opponens, M.P.extension stopL3830 CRS WHFO, addition to short and long opponens, M.P.extension assistL3835 CRS WHFO, addition to short and long opponens, M.P.spring extension assistL3840 CRS WHFO, addition to short and long opponens,spring swivel thumbL3845 CRS WHFO, addition to short and long opponens,July 2013 100-13

Children’s Specialty ClinicsProcedure Code Who Can Bill Descriptionthumb IP extension assist with M.P. stopL3850 CRS WHFO, addition to short and long opponens,action wrist, with dorsiflexion assistL3855 CRS WHFO, addition to short and long opponens,adjustable M.P. flexion controlL3860 CRS WHFO, addition to short and long opponens,adjustable M.P. flexion control and I.P.L3900 CRS WHFO, dynamic flexor hinge, reciprocal wristextension/flexion, finger flexion/extension, wrist orfinger drivenL3901 CRS WHFO, dynamic flexor hinge, reciprocal wristextension/flexion, finger flexion/extension, cabledrivenL3906 CRS WHO, wrist gauntlet, molded to patient modelL3907 CRS WHFO, wrist gauntlet with thumb spica, molded topatient modelL3908 CRS WHO, wrist extension control cock-up, non-moldedL3910 CRS WHFO, Swanson designL3912 CRS HFO, flexion glove with elastic finger controlL3914 CRS WHO, wrist extension cock-upL3916 CRS WHFO, wrist extension cock-up with outriggerL3918 CRS HFO, knuckle benderL3920 CRS HFO, knuckle bender, with outriggerL3922 CRS HFO, knuckle bender, two segments to flex jointsL3924 CRS WHFO, OppenheimerL3926 CRS WHFO, Thomas suspensionL3928 CRS HFO, finger extension, with clock springL3930 CRS WHFO, finger extension, with wrist supportL3932 CRS FO, safety pin, spring wireL3934 CRS FO, safety pin, modifiedL3936 CRS WHFO, PalmerL3938 CRS WHFO, dorsal wristL3940 CRS WHFO, dorsal wrist, with outrigger attachmentL3942 CRS HFO, reverse knuckle benderL3944 CRS HFO, reverse knuckle bender, with outriggerL3946 CRS HFO, composite elasticL3948 CRS HFO, finger knuckle benderL3950 CRS WHFO, combination Oppenheimer, with knucklebender and two attachmentsL3952 CRS WHFO, combination Oppenheimer, with reverseknuckler and two attachmentsL3954 CRS HFO, spreading handL3960 CRS Shoulder-elbow-wrist-hand orthosis (SEWHO),abduction positioning, airplane designL3962 CRS SEWHO, abduction positioning, erbs palsy designL3964* CRS SEO, mobile arm support attached to wheelchair,balanced, adjustable – Requires PriorAuthorizationL3965* CRS SEO-mobile arm support. Attached to wheelchair,balanced, adjustable rancho type – RequiresPrior AuthorizationL3966* CRS SEO, mobile arm support attached to wheel chair,balanced, reclining – Requires PriorAuthorizationL3968* CRS SEO, mobile arm support attached to wheelchair,balanced, friction arm support (friction dampeningto proximal and distal joints) – Requires PriorAuthorizationL3969* CRS SEO, mobile arm support, monosuspension armand hand support, overhead elbow forearm handsling support, yoke type arm suspension support –100-14 July 2013

Children’s Specialty Clinics 100Procedure Code Who Can Bill DescriptionRequires Prior AuthorizationL3970* CRS SEO, addition to mobile arm support, elevatingproximal arm – Requires Prior AuthorizationL3972* CRS SEO, addition to mobile arm support, offset orlateral rocker arm with elastic balance control –Requires Prior AuthorizationL3974* CRS SEO, addition to mobile arm support, supinator –Requires Prior AuthorizationL3980 CRS Upper extremity fracture orthosis, humeralL3982 CRS Upper extremity fracture orthosis, radius/ulnarL3984 CRS Upper extremity fracture orthosis, wristL3985 CRS Upper extremity fracture orthosis, forearm, handwith wrist hingeL3986 CRS Upper extremity fracture orthosis, combination ofhumeral, radius/ulnar, wrist, (example-collesfracture)L3995 CRS Addition to upper extremity orthosis, sock, fractureor equal, eachL3999* CRS Upper limb orthosis, not otherwise specified –Requires Prior AuthorizationL4000 CRS Replace girdle for Milwaukee orthosisL4010 CRS Replace trilateral socket brimL4020 CRS Replace quadrilateral socket brim, molded topatient modelL4030 CRS Replace quadrilateral socket brim, custom fittedL4040 CRS Replace molded thigh lacerL4045 CRS Replace non-molded thigh lacerL4050 CRS Replace molded calf lacerL4055 CRS Replace non-molded calf lacerL4060 CRS Replace high roll cuffL4070 CRS Replace proximal and distal upright for KAFOL4080 CRS Replace metal bands KAFO proximal thighL4090 CRS Replace metal band KAFO-AFO, calf or distal thighL4110 CRS Replace leather cuff, KAFO, calf or distal thighL4130 CRS Replace pretibial shellL4205 CRS Repair pretibial shellL4210 CRS Repair of orthotic device, repair or replace minorparts*Requires PANOTE:Refer to Chapter 37, Therapy (Occupational, Physical, and Speech) forthe therapy codes.100.5.4 Place of Service CodesThe place of service code 99 (Other Unlisted Facility) applies when filingclaims for clinic services, except for dental and orthodontia services. Fordental and orthodontia services, use place of service 11.July 2013 100-15

Children’s Specialty Clinics100.5.5 Required AttachmentsTo enhance the effectiveness and efficiency of Medicaid processing, yourattachments should be limited to the following circumstances:• Claims With Third Party DenialsRefer to Section 5.7, Required Attachments, for more information onattachments.100.6 For More InformationThis section contains a cross-reference to other relevant sections in themanual.ResourceWhere to Find ItCMS-1500 Claim Filing Instructions Section 5.2Electronic Media Claims (EMC) Submission Appendix BGuidelinesAVRS Quick Reference GuideAppendix LAlabama Medicaid Contact InformationAppendix N100-16 July 2013