5101:3-10-19 Definitions of terms associated with orthotic and prosthetic services.

The following are definitions used in rule 5101:3-10-20 of the Administrative Code.

(A) "Base procedure" - The basic procedure which indicates the simplest form of service being provided.

(B) "Additions to" - The "add-on" codes are added to the base procedure code if additional and more complicated services are provided. Normally the value assigned to the "add-on" codes does not represent the actual value of the component but only the difference in value between the base component found in the base procedure code and the "add-on" component being substituted. Those codes with asterisks can be billed either as "add-on" or as replacement items.

(C) "Molded socket" - In orthotics, this means an impression was taken, modified, and a socket of thermoplastic or other materials was made over the model. This same phrase in prosthetics indicates generally accepted fitting procedures, such as a PTB or quadrilateral socket that have been molded over a modified patient model.

(D) "Molded to consumer model" - A plaster cast is taken of the involved portion of the consumer's body from which a positive cast is then developed. This positive mold represents the patient model from which the ultimate appliance is fabricated.

(E) "Molded to consumer" - Direct molding of plastic or similar material on involved portion of consumer's body. This material is ultimately used in the appliance being fabricated.

(F) "Direct formed" - Direct molding of plastic or similar material on involved portion of

consumer's body. This material is ultimately used in the appliance being fabricated.

(G) "Nonmolded" - No casting or molding techniques used in the fabrication of the appliance in question. It can be a stock item or made from measurements and/or patterns only.

(H) "Premolded" - No casting or molding techniques used in the fabrication of the appliance in question. It can be a stock item or made from measurements and/or patterns only.

(I) "Custom fitted" - No casting or molding techniques are used in the fabrication of the appliance in question. It is normally a stock item that is fitted and adjusted to the patient. All custom-fitted items that require prior authorization must include make and model number.

(J) "Custom fabricated" - The appliance in question has been made for the consumer from measurements and/or patterns only.

(K) "Interface material" - Lining material used in any appliance. It is inserted between the body and the structural support.

(L) "Flexible" - Normally refers to surgical garments or corsets made from material, with reinforcing stays and para-spinal spring steels.

(M) "Thermoplastic or equal" - The device is fabricated from one of the various forms of thermoplastic materials that are commercially available, or in some instances may even refer to a thermosetting plastic resin approach.

(N) "Endoskeletal" - In prosthetics, this implies the modular approach and is all-inclusive of the various manufacturers of endoskeletal components.

(O) "Exoskeletal" - The traditional plastic laminated approach to finishing a prosthesis.

(P) "Immediate fit" - The application of a prosthesis in the operating or recovery room, and the appropriate cast changes.

(Q) "Initial prosthesis" - The application of a plaster direct formed BK or AK prosthesis that was not an immediate fit, and is not intended for extensive use. This is a noncovered service by medicaid.

(R) "Preparatory prosthesis" - A device that will allow for extensive gait training for lower limb amputees, and extensive functional training for upper limb amputees. A patient with a preparatory prosthesis need not be in the hospital, but is still undergoing changes to the amputation that preclude the fitting of the definitive prosthesis. Preparatory prostheses for lower limb amputees with the potential to be ambulatory will be considered for coverage by medicaid only when extensive training is medically necessary prior to the fitting of the definitive prosthesis.

(S) "Medical event" - A physical occurrence or aberration which necessitates medical intervention requiring the one-time use of an orthosis specific to the diagnosis as prescribed by a physician.

(T) "NC" - A noncovered service by medicaid.

Effective: 01/07/2010
R.C. 119.032 review dates: 10/14/2009 and 01/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/1/88, 5/1/90, 10/1/04