Updates to correct coding editing

Effective for Medicaid claims processed on or after February 1, 2025, we are updating our professional editing system to align with the Centers for Medicaid & Medicare Service (CMS) for the following services:

• Appropriate billing of anatomic right (RT) and left (LT) modifiers:
• According to CMS policy, orthotics or prosthetics that can be billed bilaterally in nature require the use of RT and/or LT (Left) modifiers to identify the side of the body where the orthotic or prosthetic service is performed. The following code groups, which are bilateral in nature, will be denied if billed without an RT or LT modifier:
• Ankle foot/knee ankle foot orthotics (KAFO)
• External breast prosthesis
• Eye prosthesis
• Facial prosthesis
• Knee and arm orthotics
• Lower limb prosthesis
• Orthopedic footwear
• Upper limb prosthesis

Claim lines not billed in accordance with the correct coding guidance outlined above will be denied. If you disagree with a claim reimbursement decision, please follow the claim dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.

If you have questions about this communication or need assistance with any other items, contact your provider relationship management representative.