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Diagnosis Specific DME
Treatment Protocols and Charting Compliance Oklahoma Podiatric Medical Association May 11, 2012 Hal Ornstein, DPM, FASPS Chairman, American Academy of Podiatric Practice Management 22 years in Private Practice Howell, New Jersey
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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
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explained on next slide
Note change of L Code... explained on next slide ***Fee Ceiling: as published for 2010
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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." 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.
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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 A They might more appropriately meet the description of L1902. In summary, some items currently filed as L1906 will need to be reclassified as L All items that meet new definition of L1906 will need a verification letter starting April 1, 2012.
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Darco Body Armor Sport ~ Sweed-O White/Black
1906 vs. 1902 L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1902 ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Darco Body Armor Sport ~ Sweed-O White/Black Suggested Code: L1906 DMEPOS Fee Ceiling: $138.87 Ossur GameDay Suggested Code: L1902 DMEPOS Fee Ceiling: $90.11
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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
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Commonly used AFO Categories/DME HCPCS Codes
L Non covered L AFO, Gauntlet style L AFO, Multiligamentous L AFO, Non-pneumatic walking L AFO, Plantarfascia night splint L AFO, Pneumatic below knee L AFO, With ankle joint L AFO, Ankle control orthotics L AFO, Dynamic L AFO, Spiral, plastic, other
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(basic coverage criteria)
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".
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Which diagnoses are covered for use of non-custom DME items (AFO's)?
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There is no diagnoses list. Devices must meet "medical justification".
* exceptions are specific criteria for night splint (L4396) and no walking boot coverage for ulcers
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Medical Justification for AFOs State Functional Benefits
Covered 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.
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Chart Notes establish “Medical Justification”
Justification for custom vs. non-custom
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Possible Diagnosis Codes:
Ankle Sprain ~ Grade 1 Possible Diagnosis Codes: Sprain and strain of ankle and foot, calcaneofibular Sprain and strain of ankle and foot, unspecified site Pain in limb Unspecified disorder of ankle and foot
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Ankle Sprain ~ Grade 1 Initial Visit
Ossur GameDay Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19
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Possible Diagnosis Codes:
Ankle Sprain ~ Grade 2 & 3 Possible Diagnosis Codes: Ankle pain and support Effusion of joint, ankle, foot Sprain and strain of ankle and foot, calcaneofibular Sprain and strain of ankle and foot, deltoid ligament Ankle fracture, lateral malleolus only Ankle fracture, trimalleolar
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Ankle Sprain ~ Grades 2 & 3 Initial Visit
SafeStep DME Adjustable Low Top Walker Ossur Equalizer Premium Air Walker SafeStep Adjustable Air Walker Ossur Rebound Air Walker Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75 All SafeStep DME Available with custom logo
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Ankle Sprain ~ Grade 2 & 3 Follow up visit, 2 - 6 weeks
Healing Well Delayed Healing Ossur GameDay Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19 Ossur Exoform Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19 Ossur Rebound Hinged Ankle Brace Suggested Code: L1971 DMEPOS Fee Ceiling: $517.14
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Possible Diagnosis Codes:
Ankle Instability Possible Diagnosis Codes: Sprain and strain of ankle and foot, calcaneofibular Sprain and strain of ankle and foot, unspecified
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Ankle Instability: Initial Visit Mild Moderate Ossur Exoform
Ossur GameDay Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19 Ossur Exoform Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19 Ossur Rebound Hinged Ankle Brace Suggested Code: L1971 DMEPOS Fee Ceiling: $517.14
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Possible Diagnosis Codes:
Plantar Fasciitis Possible Diagnosis Codes: Plantar fascial fibromatosis
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Plantar fasciitis: Initial Visit
PowerStep Insert Suggested Code: L2999 Patient Pays Aircast Airheel Suggested Code: L2999 Patient Pays
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SafeStep DME PosteriorNight Splint Night Splint ~ Posterior or Dorsal
Plantar fasciitis: Subsequent Visit SafeStep DME Dorsal Night Splint Darco Dorsal Night Splint SafeStep DME PosteriorNight Splint Night Splint ~ Posterior or Dorsal Suggested Code: L4396 DMEPOS Fee Ceiling: $184.82
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Plantar fasciitis: Subsequent Visit
Severe SafeStep DME Low Top Air Walker Ossur Rebound Low Walker Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75
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Posterior Tibialis Tendonitis Possible Diagnosis Codes:
Late effect of tendon injury, sprain, strain
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Posterior Tibialis Tendonitis Mild Initial Visit
PowerStep Insert Suggested Code: L2999 Patient Pays Aircast Airlift PTTD Suggested Code: L4350 DMEPOS Fee Ceiling: $103.23
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Posterior Tibialis Tendonitis Moderate: Initial Visit
Ossur Rebound Hinged Ankle Brace Darco Vario Suggested Code: L1971 *can also include code L2275 DMEPOS Fee Ceiling: $517.14 Suggested Code: L1971 DMEPOS Fee Ceiling: $517.14
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Posterior Tibial Tendonitis Severe, Initial Visit
Ossur Equalizer Premium Air Walker SafeStep DME Air Walker Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75
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Posterior Tibialis Tendon Rupture Possible Diagnosis Codes:
Stage 3 Possible Diagnosis Codes: Rupture, tendon of foot and ankle, non-traumatic Laxity of ligament Flat foot, acquired
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Posterior Tibialis Tendon Rupture, Stage 3: Initial Visit
SafeStep DME Air Walker Ossur Rebound Air Walker Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75
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Posterior Tibialis Strain Subsequent Visit, if getting better
Rupture, Stage 3: Subsequent Visit, if getting better Less Severe More Severe Ossur Rebound Aircast Airlift PTTD Suggested Code: L4350 DMEPOS Fee Ceiling: $103.23 Darco Vario Suggested Code: L1971 DMEPOS Fee Ceiling: $517.14
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Posterior Tibialis Tendon Rupture ~ Stage 3:
Subsequent Visit, if getting worse Arizona Standard AFO Suggested Codes: L1940, L2330, L2820 DMEPOS Fee Ceiling: $1099 AZ Split Upright or Richie AFO Suggested Codes: L1970, L2820 DMEPOS Fee Ceiling: $901
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Tarsal Tunnel Syndrome Possible Diagnosis Codes:
Pain in joint, ankle, foot
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Tarsal Tunnel Syndrome:
Initial Visit Mild Moderate Ossur GameDay Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19 Ossur Exoform Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19 Ossur Rebound Hinged Ankle Brace Suggested Code: L1971 DMEPOS Fee Ceiling: $517.14
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Severe Tarsal Tunnel Syndrome Initial Visit
SafeStep DME Low Top Air Walker Ossur Rebound Low Top Air Walker All SafeStep DME Available with custom logo Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75
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Severe Tarsal Tunnel Syndrome:
Subsequent Visit Aircast Airlift PTTD Suggested Code: L4350 DMEPOS Fee Ceiling: $103.23 Ossur GameDay Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19
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Possible Diagnosis Codes:
Peroneal Tendonitis Possible Diagnosis Codes: Enthesopathy of ankle and tarsus
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Peroneal Tendonitis Initial Visit
Mild to Moderate Ossur Game Day Suggested Code: L1902 DMEPOS Fee Ceiling: $92.19
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Peroneal Tendonitis ~ Severe Initial Visit
SafeStep Low Top Air Walker Ossur Equalizer Premium Air Walker Aircast SP Walker Ossur Rebound Air Walker Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75
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Achilles Tendonitis Achilles Tendon Rupture Possible Diagnosis Codes:
Achilles tendon strain, rupture Achilles tendonitis
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Achilles Tendonitis ~ Achilles Tendon Tear Initial Visit
SafeStep DME Air Walker Ossur Rebound Air Walker Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75
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Posterior Night Splint Night Splint ~ Posterior or Dorsal
Achillies Tendonitis with Plantar Flexion Contracture of the Ankle (718.47) Initial Visit Ossur Formfit Posterior Night Splint SafeStep DME Dorsal Night Splint Ossur Airform Dorsal Night Splint Night Splint ~ Posterior or Dorsal Suggested Code: L4396 DMEPOS Fee Ceiling: $184.82
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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
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Possible Diagnosis Codes:
Metatarsal Fracture Possible Diagnosis Codes: Stress fracture, unspecified Fracture of the metatarsal bone
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Non-Pnematic Low Top Walker DMEPOS Fee Ceiling: Patient pays
Metatarsal Fracture: Initial visit SafeStep DME Non-Pnematic Low Top Walker Suggested Code: L4386 DMEPOS Fee Ceiling: $174.36 Darco Med-Surg Walker Suggested Code: L2999 DMEPOS Fee Ceiling: Patient pays
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Metatarsal Fracture: Follow up visit
PowerStep ProTech Prefabricated Orthotic Suggested Code: L2999 DMEPOS Fee Ceiling: Patient pays
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Possible Diagnosis Codes:
Flaccid Drop Foot Possible Diagnosis Codes: Acquired deformity of foot and ankle Hemiplegia Joint derangement, ankle and foot Peroneal muscle atrophy, Charcot Marie Tooth disease Multiple sclerosis Poliomyelitis, late effects
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Flaccid Drop Foot : Initial Visit Euro International Peromax
Suggested Code: L1951 DMEPOS Fee Ceiling: $926
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Chart Documentation
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Chart Documentation
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Chart Documentation
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Chart Documentation
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Frequently asked questions and answers
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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.
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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.
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When can a person get another device?
Upon examination and documentation of change in status. Medical justification is established chart notes.
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***Not responsible for typographical errors.
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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Thank you!
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