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Orthotics and prosthetic appliances and appropriate use of RT/LT modifiers

Release Date: April 26, 2012

Blue Cross and Blue Shield of North Carolina (BCBSNC) will provide coverage for orthotic and prosthetic appliances when; (1) they are determined to be medically necessary because the medical criteria and guidelines have been met as outlined in our Corporate Medical Policy, and (2) a member’s individual policy includes coverage for a service provided.  As part of our commitment to ensuring your claims for these services process in a timely and accurate manner, we would like to provide clarity around the appropriate use of the RT (Right) and LT (Left) modifiers when billed for orthotic and prosthetic devices. 

Orthotics and/or prosthetics when billed bilaterally require the use of the RT or LT modifier.  RT and LT modifiers define which side is being supported (orthotic) or replaced (prosthetic).  Claims submitted to BCBSNC with the modifier 50 (bilateral procedure), will be denied. 

Below are a few examples of orthotic and prosthetic appliances requiring the use of the RT and LT modifiers:

  • Ankle Foot/Knee Orthotics (KAFO)
  • Knee and Arm Orthotics
  • Orthotic Footwear
  • Lower Limb Prosthesis
  • Upper Limb Prosthesis
  • External Breast Prosthesis
  • Facial Prosthesis
  • Eye Prosthesis

As a BCBSNC participating provider, you are responsible for accurate submission of claims.  BCBSNC’s reimbursement policies ensure that your practice is reimbursed based on the code(s) that accurately describe the health care service(s) provided.  BCBSNC benefits may vary according to benefit design.  Therefore, certificate language should always be reviewed before applying the terms of the BCBCNC billing and claim submission policies.  At times, it may be necessary for BCBSNC to request medical records for determination of medical necessity.  When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. 

BCBSNC Corporate Medical Policy for Orthotic and Prosthetic Appliances can be viewed online at www/bcbsnc.com/providers.  Questions regarding BCBSNC’s billing policies and procedures should be directed to your regional Strategic Provider Relations representative or contact the Provider Blue LineSM at 1-800-214-4844