MedicaidPrior AuthHigh impact
Newsletter Vol. 26, No. 09
New Jersey Medicaid·NJ · Podiatry, Orthopedics, Physical Therapy·Coding
Effective date
Aug 1, 2016
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJ FamilyCare FFS) updated ICD-10-CM diagnosis code requirements for orthotics, shoes, and foot supports billing, effective immediately. Specific HCPCS codes (L3000-L3090, L3201-L3223) now bypass prior authorization only when paired with approved ICD-10-CM diagnosis codes listed in the attachment. Claims using unapproved diagnosis codes will be denied with Error Code 0251. Coverage frequency limits apply: 2 pairs of shoes/year, 4 single shoes/year, 2 pairs of foot supports/year, and 4 castings/year per beneficiary per provider per 12-month period.
Action Required
Immediately: Billing team must update billing system and claims submission processes for all New Jersey Medicaid (NJ FamilyCare FFS) orthotics and shoe claims. (1) Configure system to require ICD-10-CM diagnosis codes from the attached list for HCPCS codes L3000-L3090 and L3201-L3223 to bypass prior authorization; all other diagnosis codes for these procedures require prior authorization. (2) Implement frequency limits in billing software: L3201-L3207, L3215-L3217, L3219, L3221-L3222 limited to 2 units per 12 months (2 pairs shoes/year); L3218, L3223, L3250-L3253 limited to 4 units per 12 months (4 single shoes/year); L3001, L3030, L3040, L3050, L3060, L3070, L3080, L3090 limited to 2 units per 12 months (1 pair foot supports/year); X4890-X4892 limited to 4 units per 12 months (4 castings/year). (3) Configure system to deny claims with Error Code 0251 'Deny for Diagnosis' when incorrect ICD-10-CM codes are used; Error Code 734 'Exceeds Program Frequency Guidelines' when frequency limits exceeded. (4) Train billing staff and providers on approved ICD-10-CM diagnosis code requirements and new frequency guidelines. (5) Disregard prior guidance in Newsletters Volume 13, No. 25 and No. 41 for service dates on or after October 1, 2015. Non-compliance will result in claim denials and potential recovery actions by State of New Jersey for fraudulent diagnosis code reporting.