Diagnosis Specific DME Treatment Protocols
and Charting Compliance
Oklahoma Podiatric Medical AssociationMay 11, 2012
Hal Ornstein, DPM, FASPSChairman, American Academy ofPodiatric Practice Management
22 years in Private PracticeHowell, New Jersey
Reasons To Follow Treatment Protocols
Easy to follow Consistent with standards of care Medico-legal security Ease of inventorying Improved outcomes Improved patient satisfaction Patient convenience
Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 (ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT) are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification Matrix of the DME Coding System (DMECS). Products which have not received coding verification review from the PDAC must be billed with code A9270. Please refer to the advisory article titled Coding Guidelines for Ankle Foot Orthoses.
Recently, Medicare announced that the design of an L1906 device must "include a rigid
stirrup and foot plate which provides functional tracking of the ankle with hind-foot
and mid-foot stability during ambulation."
In summary, some items currently filed as L1906 will need to be reclassified as
L1902. All items that meet new definition of L1906 will need a
verification letter starting April 1, 2012.
Products that are currently listed on DMECS with L1906 will be end dated effective March 31, 2012 and changed to A9270 until a coding verification review has been completed by the PDAC.Thus, it is mandatory that manufacturers submit to PDAC devices for L1906 verification in order for them to qualify for reimbursement.There are some multiligamentous type devices that have been recommended to be billed using L1906 code such as the Ossur Exoform and the GameDay that do not have a foot plate. As such, they would need to be billed as A9270. They might more appropriately meet the description of L1902.
1906 vs. 1902L1906
ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
L1902ANKLE FOOT ORTHOSIS,
ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
Ossur GameDay Suggested Code: L1902
DMEPOS Fee Ceiling: $90.11
Darco Body Armor Sport ~ Sweed-O White/Black
Suggested Code: L1906DMEPOS Fee Ceiling: $138.87
Dear Ms. Williams:The Pricing, Data Analysis, and Coding (PDAC) Contractor provides Healthcare Common Procedural Coding System (HCPCS) assistance to manufacturers to ensure proper coding of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. The PDAC has reviewed the above listed products. It is our determination that the Medicare HCPCS code to use when billing the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) is:L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT,PREFABRICATED, INCLUDE'S FITTING AND ADJUSTMENT
Commonly used AFO Categories/DME HCPCS Codes
L2999 Non coveredL1902 AFO, Gauntlet styleL1906 AFO, MultiligamentousL4386 AFO, Non-pneumatic walkingL4396 AFO, Plantarfascia night splintL4360 AFO, Pneumatic below kneeL1971 AFO, With ankle jointL4350 AFO, Ankle control orthotics L1932 AFO, DynamicL1951 AFO, Spiral, plastic, other
When to use these L Codes…(basic coverage criteria)
"Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally".
There is no diagnoses list. Devices must meet "medical
justification".
* exceptions are specific criteria for night splint (L4396) and
no walking boot coveragefor ulcers
Medical Justification for AFOs
State Functional BenefitsCovered for ambulatory patients with weakness or deformity of the foot and ankle who require stabilization and have the potential to benefit functionally.
AFO must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used to brace.
Ankle Sprain ~ Grade 1
Possible Diagnosis Codes:845.02 Sprain and strain of ankle and foot, calcaneofibular 845.00 Sprain and strain of ankle and foot, unspecified site729.5 Pain in limb719.07 Unspecified disorder of ankle and foot
Ankle Sprain ~ Grade 2 & 3
Possible Diagnosis Codes:729.5 Ankle pain and support719.07 Effusion of joint, ankle, foot845.02 Sprain and strain of ankle and foot, calcaneofibular845.01 Sprain and strain of ankle and foot, deltoid ligament824.2 Ankle fracture, lateral malleolus only824.6 Ankle fracture, trimalleolar
Ankle Sprain ~ Grades 2 & 3
Initial Visit
Pneumatic WalkerSuggested Code: L4360
DMEPOS Fee Ceiling: $319.75
SafeStep Adjustable Air
Walker
Ossur Rebound Air Walker
Ossur Equalizer
Premium Air Walker
SafeStep DME
Adjustable Low Top Walker
All SafeStep DME Available with custom
logo
Ankle Sprain ~ Grade 2 & 3 Follow up visit, 2 - 6 weeks
Suggested Code: L1971DMEPOS Fee Ceiling:
$517.14
Delayed Healing
Healing Well
Ossur ReboundHinged Ankle
Brace
Ossur GameDay Suggested Code:
L1902DMEPOS Fee Ceiling:
$92.19
Ossur Exoform Suggested Code:
L1902DMEPOS Fee Ceiling:
$92.19
Ankle Instability
Possible Diagnosis Codes:845.02 Sprain and strain of ankle and foot, calcaneofibular845.00 Sprain and strain of ankle and foot, unspecified
Ankle Instability: Initial Visit
Mild Moderate
Suggested Code: L1971DMEPOS Fee Ceiling:
$517.14
Ossur ReboundHinged Ankle
Brace
Ossur GameDay Suggested Code: L1902
DMEPOS Fee Ceiling: $92.19
Ossur Exoform Suggested Code:
L1902DMEPOS Fee Ceiling:
$92.19
Plantar fasciitis: Initial Visit
Aircast AirheelSuggested Code:
L2999Patient Pays
PowerStep InsertSuggested Code:
L2999Patient Pays
Plantar fasciitis: Subsequent Visit
Night Splint ~ Posterior or Dorsal
Suggested Code: L4396DMEPOS Fee Ceiling: $184.82
SafeStep DME Dorsal Night Splint
Darco Dorsal Night Splint
SafeStep DME PosteriorNight Splint
Plantar fasciitis: Subsequent Visit
Pneumatic WalkerSuggested Code: L4360
DMEPOS Fee Ceiling: $319.75
Severe
Ossur Rebound Low Walker
SafeStep DME Low Top Air Walker
Posterior Tibialis Tendonitis
Possible Diagnosis Codes:726.72 Tibialis tendonitis905.8 Late effect of tendon injury, sprain, strain
Posterior Tibialis Tendonitis Mild Initial Visit
Aircast Airlift PTTDSuggested Code: L4350
DMEPOS Fee Ceiling: $103.23
PowerStep Insert
Suggested Code: L2999
Patient Pays
Posterior Tibialis Tendonitis Moderate: Initial Visit
Suggested Code: L1971DMEPOS Fee Ceiling:
$517.14
Ossur ReboundHinged Ankle
Brace
Darco VarioSuggested Code: L1971
*can also include code L2275
DMEPOS Fee Ceiling: $517.14
Posterior Tibial Tendonitis Severe, Initial Visit
Pneumatic WalkerSuggested Code: L4360
DMEPOS Fee Ceiling: $319.75
SafeStep DME Air Walker
Ossur Equalizer Premium Air Walker
Posterior Tibialis Tendon RuptureStage 3
Possible Diagnosis Codes:727.68 Rupture, tendon of foot and ankle, non-traumatic728.4 Laxity of ligament734 Flat foot, acquired
Posterior Tibialis Tendon Rupture, Stage 3: Initial
Visit
Pneumatic Walker
Suggested Code: L4360DMEPOS Fee Ceiling:
$319.75
Ossur Rebound Air Walker
SafeStep DME Air Walker
Posterior Tibialis Strain Rupture, Stage 3:
Subsequent Visit, if getting better
Aircast Airlift PTTDSuggested Code:
L4350DMEPOS Fee Ceiling:
$103.23
Less Severe
Darco Vario
More Severe
Ossur Rebound
Suggested Code: L1971DMEPOS Fee Ceiling:
$517.14
Posterior Tibialis TendonRupture ~ Stage 3:
Subsequent Visit, if getting worse
Arizona Standard AFOSuggested Codes: L1940, L2330,
L2820DMEPOS Fee Ceiling: $1099
AZ Split Upright or Richie AFOSuggested Codes: L1970,
L2820DMEPOS Fee Ceiling: $901
Tarsal Tunnel Syndrome
Possible Diagnosis Codes:355.5 Tarsal tunnel syndrome719.47 Pain in joint, ankle, foot
Tarsal Tunnel Syndrome: Initial Visit
Mild Moderate
Suggested Code: L1971DMEPOS Fee Ceiling:
$517.14
Ossur GameDay
Suggested Code: L1902DMEPOS Fee Ceiling:
$92.19
Ossur ReboundHinged Ankle
Brace
Ossur Exoform
Suggested Code: L1902DMEPOS Fee Ceiling:
$92.19
Severe Tarsal Tunnel Syndrome Initial Visit
Pneumatic WalkersSuggested Code: L4360
DMEPOS Fee Ceiling: $319.75
Ossur Rebound Low Top Air
Walker
SafeStep DME Low Top Air Walker
All SafeStep DME
Available with custom logo
Severe Tarsal Tunnel Syndrome:
Subsequent Visit
Ossur GameDay Aircast Airlift PTTDSuggested Code:
L4350DMEPOS Fee
Ceiling: $103.23
Suggested Code: L1902DMEPOS Fee Ceiling:
$92.19
Peroneal Tendonitis Initial VisitMild to Moderate
Ossur Game Day Suggested Code:
L1902DMEPOS Fee Ceiling:
$92.19
Peroneal Tendonitis ~ SevereInitial Visit
Pneumatic WalkersSuggested Code: L4360
DMEPOS Fee Ceiling: $319.75
Aircast SP Walker Ossur Rebound Air Walker
SafeStepLow Top Air Walker
Ossur Equalizer Premium Air
Walker
Achilles Tendonitis Achilles Tendon
Rupture
Possible Diagnosis Codes:845.09 Achilles tendon strain, rupture726.71 Achilles tendonitis
Achilles Tendonitis ~ Achilles Tendon Tear Initial Visit
Pneumatic WalkersSuggested Code: L4360
DMEPOS Fee Ceiling: $319.75
Ossur Rebound Air WalkerSafeStep DME Air Walker
Achillies Tendonitis with Plantar Flexion Contracture of the Ankle
(718.47)Initial Visit
Night Splint ~ Posterior or Dorsal
Suggested Code: L4396DMEPOS Fee Ceiling: $184.82
Ossur Formfit Posterior Night Splint
Ossur AirformDorsal Night Splint
SafeStep DME Dorsal Night Splint
Achillies Tendonitis with Plantar Flexion Contracture of the Ankle
(718.47): Prerequisite to qualify for Medicare billing: Requires dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and,Reasonable expectation of the ability to correct the contracture; and,Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; and,Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons
Metatarsal Fracture
Possible Diagnosis Codes:733.94 Stress fracture, unspecified825.25 Fracture of the metatarsal bone
Metatarsal Fracture: Initial visit
SafeStep DME Non-Pnematic Low Top
WalkerSuggested Code: L4386
DMEPOS Fee Ceiling: $174.36
Darco Med-Surg WalkerSuggested Code: L2999
DMEPOS Fee Ceiling: Patient pays
Metatarsal Fracture: Follow up visit
PowerStep ProTech Prefabricated Orthotic
Suggested Code: L2999DMEPOS Fee Ceiling: Patient pays
Flaccid Drop Foot
Possible Diagnosis Codes:736.79 Acquired deformity of foot and ankle438.20 Hemiplegia719.97 Joint derangement, ankle and foot356.1 Peroneal muscle atrophy, Charcot Marie Tooth disease340 Multiple sclerosis138 Poliomyelitis, late effects
Flaccid Drop Foot : Initial Visit
Euro International Peromax
Suggested Code: L1951
DMEPOS Fee Ceiling: $926
What if patient doesn't come in to pick up custom device?
After several attempts made to contact person and to no avail... the COST of the custom device can be billed to Medicare/Insurance. Send original invoice and explanation of no show for custom device pickup.
What if person dies?
As in the previous situation; the COST of the custom device can be billed to Medicare/Insurance. Send original invoice and explanation of death of patient.* Payment may reflect full ceiling fee, in that case, you are not obligated to refund Medicare. Keep full payment.
Upon examination and documentation of change in status. Medical justification is established chart notes.
When can a person get another device?
Disclaimer:
Suggested codes are based on publicly available information and are offered as a convenience to physicians. The authors make no claims, promises or guarantees as to the availability of reimbursement for any of the suggested products. It is within the sole discretion of physicians to determine the appropriate billing code for a product as well as whether the use of a product complies with medical necessity and other documentation requirements of the payor. Actual reimbursement may vary. Prices reflect 2012 HCPCS National Ceiling Fees.
***Not responsible for typographical errors.
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