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Newsletter Vol. 26, No. 09
Act
immediately
Effective date
Aug 1, 2016
Identified
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.
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What to do
immediately · 7 steps
01Billing team must update billing system and claims submission processes for all New Jersey Medicaid (NJ FamilyCare FFS) orthotics and shoe claims.
02Configure 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.
03Implement 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).
04Configure 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.
05Train billing staff and providers on approved ICD-10-CM diagnosis code requirements and new frequency guidelines.
06Disregard prior guidance in Newsletters Volume 13, No. 25 and No. 41 for service dates on or after October 1, 2015.
07Non-compliance will result in claim denials and potential recovery actions by State of New Jersey for fraudulent diagnosis code reporting.
Codes mentioned
L3000L3001L3002L3003L3010L3020L3030L3040L3050L3060L3070L3080L3090L3201L3202L3203L3204L3205L3206L3207L3215L3216L3217L3218L3219L3221L3222L3223L3250L3251L3252L3253X4890X4891X4892
Original notice
Newsletter Vol. 26, No. 09
njmmis.com · Always check the source before changing claims.
Related changes
See all New Jersey Medicaid changes →Related policy hubs
New Jersey Medicaid policiesNJ policy changesPodiatryOrthopedicsPhysical TherapyCode L3000Code L3001Code L3002Code L3003Code L3010Code L3020Code L3030Code L3040Code L3050Code L3060Code L3070Code L3080Code L3090Code L3201Code L3202Code L3203Code L3204Code L3205Code L3206Code L3207Code L3215Code L3216Code L3217Code L3218Code L3219Code L3221Code L3222Code L3223Code L3250Code L3251Code L3252Code L3253Code X4890Code X4891Code X4892