External Prostheses and Orthoses

The TAC Medical Excess may apply to these services 

 

 

 

POLICY

The TAC can pay the reasonable costs of external prostheses and orthoses where required as a result of a transport accident injury under section 60 of the Transport Accident Act 1986 (the Act).

This policy must be read in conjunction with the following:

This policy does not apply to surgically implanted prostheses. Refer to the Surgically Implanted Prostheses policy.

BACKGROUND

External prostheses
An external prosthesis is an artificial device that replaces a missing body part for functional and/or cosmetic reasons, including artificial limbs, facial features and digits. External prostheses can consist of components, such as feet and knee components, but do not include surgically implanted prostheses.

External prostheses are sometimes provided in three stages:

  • initial interim prostheses following amputation or residual limb revision including trial components
  • subsequent interim prostheses as the residual limb matures or due to a change in functional status
  • definitive prostheses once the size and shape of the residual limb has stabilised.

Different types of external prostheses can be prescribed depending on their purpose:

  • general prostheses prescribed for everyday activity and function (including a back-up prosthesis for use when the everyday prosthesis is sent away for maintenance or repair)
  • sporting or recreational prostheses for general sporting or recreational activities (can be provided in addition to a general prosthesis)
  • elite sporting or recreational prosthesis (in exceptional circumstances for elite events or activities).

Osseo-integration for prostheses
Osseo-integration is an elective surgical procedure that may be required as part of the client's prosthetic management. Refer to the Surgery Requests Elective policy and Non-Established, New or Emerging Treatments and Services policy.

Orthoses
An orthosis is a brace or splint used to support, align, prevent or correct musculoskeletal irregularities to improve function.

DEFINITIONS

In this policy:

  • A facial prosthesis replaces a lost facial feature, including the eyes, noses and ears.
  • A prosthetic digit replaces lost fingers and toes.
  • A condemned prosthesis means the prosthesis is no longer able to be used as it is clinically inappropriate or unsafe
  • Consumables are items associated with the use of prostheses and orthoses that require regular replacement e.g. residual limb socks, plaster casts, sheaths.
  • Minor repairs are any repairs to a prosthesis that cost less than $250 (including consumables, materials, consultation and manufacturing time).
  • A major repair is a repair of a prosthesis that costs over $250 that does not require a change of prescription. For example, replacement of a socket, service of componentry, adjustment.
  • Maintenance of a prosthesis means any service required to maintain the function of a prosthesis and adhere to warranty requirements. For example, periodic servicing of microprocessor units.

GUIDELINES

What can the TAC pay for in relation to external prostheses and orthoses?

The TAC can pay the reasonable costs of external prostheses and orthoses:

  • required as a result of a transport accident injury
  • where safe and effective
  • where the prosthesis or orthosis promotes functional independence, self-management or cosmetic improvement.

In relation to orthoses, the TAC can pay the reasonable costs of prescription, manufacture, supply and fitting of an orthosis. The TAC can pay the reasonable costs of the repair, adjustment or replacement of a pre-existing orthosis damaged in a transport accident.

In relation to external prostheses, the TAC can pay the reasonable costs of:

  • prescription, manufacture, supply and fitting of initial interim, subsequent interim, definitive and back up prostheses
  • maintenance of a prosthesis for its serviceable life
  • modification or replacement of a prosthesis that becomes ill-fitting or is no longer serviceable when a change of prescription is provided
  • repair, modification or replacement of a prosthesis required outside the manufacturer’s warranty
  • repair, adjustment or replacement of a pre-existing external prosthesis damaged as a result of a transport accident injury
  • specialised, higher-end prostheses and prosthetic componentry when supported by objective clinical evidence that the prescription will result in a demonstrated improved functional outcome for the client
  • prosthetic components that comply with ISO 10328 and the Therapeutic Goods (Medical Devices) Regulations 2002 (Cth).

Prostheses for sporting or recreation activities
The TAC can pay the reasonable costs of an entry level sporting or recreational prosthesis for:

  • one sporting/recreational activity where the client can demonstrate a willingness and/or capacity to commit to continued participation
  • more than one form of sporting or recreational activity when the client can demonstrate pre-accident commitment to more than one sporting or recreational activity.

Elite level sporting or recreational prostheses
The TAC can pay the reasonable costs of an entry level sporting or recreational prosthesis as a contribution towards the total cost of an elite level prosthesis. The client will be required to pay the difference between the entry level and elite level prosthesis.

Who may provide prosthetic and orthotic services?

Prosthetic services may be:

  • prescribed, manufactured/supplied and fitted by a qualified prosthetist, or
  • prescribed by a registered medical practitioner who specialises in rehabilitation, in conjunction with a qualified prosthetist.

Facial prostheses or prosthetic digit services may be prescribed by a registered medical practitioner specialising in either facial prostheses or prosthetic digit services and may be manufactured/supplied and fitted by a suitably qualified health professional such as a dental prosthetist, maxillofacial prosthetist or technician.

Orthotic services may be provided by:

  • a qualified orthotist, or
  • a physiotherapist, podiatrist, chiropractor, osteopath or
  • an occupational therapist.

What information does the TAC require to consider paying for external prostheses and orthoses?

To expedite payment of accounts, the TAC encourages prior approval to be sought by the client's treating practitioner prior to the prostheses, orthoses or services being provided (with the exception of minor prosthetic repairs).

Prostheses

Minor repairs
Prior approval is not required for minor repairs to a prosthesis.

Provision of new prostheses and maintenance, major repair, replacement or modification services for existing prostheses
A Prosthetic Treatment Request Form must be submitted to the TAC. Clinical justification of the need for services due to the transport accident injury, and details about current function, limitations, predicted outcomes and cost must be provided. See also Prosthetic Treatment Request Form notes.

Urgent major repairs
For urgent major repairs, the information required in the Prosthetic Treatment Request Form may be provided verbally. The TAC may give a verbal approval for the repairs on the condition that the Prosthetic Treatment Request Form is completed and provided within 10 working days. 

Facial Prostheses or prosthetic digits
For facial prostheses and prosthetic digits, a copy of the specialist medical practitioner request is required in addition to the Prosthetic Treatment Request Form.

Prosthetic Management
The TAC may request submission of a Prosthetics Management Review Lower Extremity Form or a Prosthetics Management Review Upper Extremity Form within three months of the final fitting of a prosthesis. See also the Management Review Lower/Upper Extremity Form notes.

Orthoses
Prior approval from the TAC is required before orthoses that cost more than $250 are provided to a client who is treated:

  • at a private practice or
  • as a hospital outpatient.

For orthoses provided to an inpatient of a hospital, please refer to the relevant hospital policy.

An Orthotic Device Request Form must be submitted to the TAC and prior approval obtained before these services are provided. Clinical justification of the need for services due to the transport accident injury, and details about current function, limitations, predicted outcomes and cost must be provided. 

When will the TAC respond to a request?

The TAC will respond to written treatment and service requests as set out in the TAC Service Charter.

To assist the TAC to make a decision, the request may be reviewed by the TAC Clinical Panel. The Clinical Panel may contact the treating health practitioner to seek further information and/or discuss the proposed services prior to making a recommendation to the TAC. The TAC will respond to the request when they have received the Clinical Panel's recommendation.

What are the TAC's invoice requirements?

Please refer to the TAC Prosthetics and Orthotics Billing Standards information sheet.

Minor repairs can be invoiced directly to the TAC.

What fees are payable for external prostheses and orthoses?

Inpatient
The TAC may not be able to pay for a prosthesis or orthosis where provided to a client as a hospital inpatient. See the relevant hospital policy or check with the referring hospital.

Outpatient
See the Department of Health Schedule of Fees and Charges for Acute Health Services in Victoria.

Private practice
For services and componentry provided in a private practice, refer to the Schedule of Fees for Prosthetic and Orthotic Services (for use by prosthetists and orthotists only)

In determining the reasonable costs payable for a prosthesis the TAC will take into account:

  • any significant changes in the residual limb shape and size, for example, following surgical revision of the residual limb, weight loss or gain or growth of a child.
  • normal wear and tear
  • the activity level of the client and types of activities that the client performs
  • any anticipated changes in the client's level of function and range of activities performed while using the prosthesis such as home, work duties or sport participation
  • the componentry costs and 
  • whether the components can be reused in the replacement prosthesis, comply with ISO 10328 or equivalent and the Therapeutic Goods (Medical Devices) Regulations 2002 (Cth), and have current manufacturer warranties.

In relation to external prostheses and orthoses, what won't the TAC pay for?

The TAC will not pay for:

  • repair or replacement of a prosthesis that the TAC did not pay for or was not damaged as a result of the transport accident injury
  • repair or replacement of an orthosis that was not damaged in the transport accident
  • maintenance, repair, modification or replacement of a prosthesis or orthosis under warranty
  • a replacement prosthesis, where the original prosthesis remains serviceable and there is no prescription change 
  • repairs to a condemned prosthesis
  • supply of a reused prosthesis 
  • services for a person other than the client
  • services subcontracted to, or provided by a non-registered provider
  • services provided outside the Commonwealth of Australia
  • the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
  • services where there is no National Health and Medical Research Council level 1 or 2 evidence that they are safe and effective. Refer to the Non-Established, New or Emerging Treatments and Services policy
  • a prosthesis or prosthetic services provided more than two years prior to the request for funding except where the request for payment is made within three years of the transport accident.  Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.

Where the TAC has paid for a prosthesis the following conditions also apply:

  • The prosthesis and its components must not be sold or traded, or disposed of without consultation with the treating prosthetist.
  • No modifications, additions or alterations may be made to the prosthesis without consultation with the treating prosthetist.
  • The TAC expects that reasonable care is taken to prevent damage, loss or theft of the prosthesis. 

Prosthetic and Orthotic Services

Effective 1 July 2017

Service Description TAC Item Number 2017/18 Maximum Payment Rate2016/17 Maximum Payment Rate
Initial Consultation PR600 $58.15 $57.30
Standard Consultation  PR602 $46.53 $45.85
Long Consultation  PR604 $69.54 $68.53
Prolonged Consultation  PR606 $92.93 $91.57
Manufacture
Time to manufacture (per hour) (Greater than 1 hour should be charged pro-rata at hourly rate) PR608 $100.94 $99.47
Purchase of Standard Products / Equipment
Standard products require the prior approval of the TAC and are payable at cost.
Details of the products must be included on the invoice for payment. PR 610 As approved As approved
Major Repair (Prosthesis) PR 614 As approved As approved
Total cost of consumables and materials only. Consultation and/or manufacturing time to be billed separately under corresponding item numbers. (Major repairs are any repairs above $250 inclusive of consumables)
New prostheses or change of prescription. (Total cost of consumables and materials only. Consultation and/or manufacturing time to be billed separately under corresponding item numbers) PR 612 As approved As approved
Prosthetic Management Review Form - lower extremity or upper extremity. (Total cost for completion of Form) PR 618* $51.31 $50.56
Orthosis (purchase)- Providers to use when submitting invoice for payment for orthotic equipment, aids & appliances - not to be used for clinical or manufacturing services - use of PR codes to be used for these service types EQ 0035 As approved As approved
Standard Consultation      - up to 30 minutes
Long Consultation             - >30 minutes < 45 minutes
Prolonged Consultation    - >45 minutes <60 minutes

Fees for prosthetist and orthotist services including equipment, provided within a public hospital will be based on the Department of Human Services schedule of fees and charges for acute health services in Victoria. Refer to www.health.vic.gov.au/feesman.

GST

*The TAC maximum fee includes a 10% allowance for GST for items which TAC believes are taxable supplies.  If you are a provider not registered for GST:

  • You are not legally permitted to charge GST
  • You should indicate on all invoices submitted your status as 'not registered for GST purposes'
  • The TAC will only reimburse you an amount which excludes the GST component for items billed where the maximum fee includes a 10% allowance for GST

If you are not registered for GST please state on all invoices the TAC item number listed for providers not registered.


View Prosthetics: management review lower extremity form

Prosthetics: management review lower extremity form

Summary:

This form is used to review the prosthetic management of TAC clients and measure progress against the predicted outcomes that were specified in the initial Prosthetic Treatment Request Form. This form is specifically for clients who have a lower extremity prosthetic device.

View Prosthetics: management review upper extremity form

Prosthetics: management review upper extremity form

Summary:

This form is used to review the prosthetic management of TAC clients and measure progress against the predicted outcomes that were specified in the initial Prosthetic Treatment Request Form. This form is specifically for clients who have a upper extremity prosthetic device.

View Prosthetics: treatment request form

Prosthetics: treatment request form

Summary:

This form is used to request prosthetic treatment for TAC clients. It covers requests for new prosthetic devices as well as major repairs and changes of prescription. The provider needs to provide details of the proposed prothesis prescription and information to support the requested services and hours.