1. Diagnosis Specific DME Treatment Protocols Super Saver Cleveland, Ohio October 28, 2010 Hal Ornstein, DPM, FASPS AAPPM Chairman Private Practice Howell, New Jersey

2. Reasons To Follow These Protocols... Improved outcomes Easy to follow Medico-legal security Improved patient satisfaction Patient convenience Ease of inventorying Consistent with standards of care

5. ***Fee Ceiling: as published for 2010

6. Commonly used Prefabricated AFO Categories/DME HCPCS Codes L2999 Non covered L1902 AFO, Gauntlet style L1906 AFO, Multiligamentous L4386 AFO, Non-pneumatic walking L4396 AFO, Plantarfascia night splint L4360 AFO, Pneumatic below knee L1971 AFO, With ankle joint L4350 AFO, Ankle control orthotics L1932 AFO, Dynamic L1951 AFO, Spiral, plastic, other

7. 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 site 729.5 Pain in limb 719.07 Unspecified disorder of ankle and foot

8. Ankle Sprain ~ Grade 1 Initial Visit Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

9. Ankle Sprain ~ Grade 2 & 3 Possible Diagnosis Codes: 729.5 Ankle pain and support 719.07 Effusion of joint, ankle, foot 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.01 Sprain and strain of ankle and foot, deltoid ligament 824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar

10. Ankle Sprain ~ Grades 2 & 3 Initial Visit Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Aircast SP Walker Ossur Rebound Air Walker Ossur Equalizer Low Top Air Walker Ossur Equalizer Premium Air Walker

11. Ankle Sprain ~ Grade 2 & 3 Follow up visit, 2 - 6 weeks Suggested Code: L1971 DMEPOS Fee Ceiling: $505 Delayed Healing Healing Well Donjoy Velocity ES Ossur Rebound Hinged Ankle Brace Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

12. Ankle Instability Possible Diagnosis Codes: 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.00 Sprain and strain of ankle and foot, unspecified

13. A nkle Instability: Initial Visit MildModerate Suggested Code: L1971 DMEPOS Fee Ceiling: $505 Ossur Rebound Hinged Ankle Brace Donjoy Velocity ES Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

14. Plantar Fasciitis Possible Diagnosis Codes: 728.71Plantar fascia fibromatosis

15. Plantar fasciitis: Initial Visit Aircast Airheel Suggested Code: L2999 Patient Pays PowerStep Insert Suggested Code: L2999 Patient Pays

16. Plantar fasciitis: Subsequent Visit Night Splint ~ Posterior or Dorsal Suggested Code: L4396 DMEPOS Fee Ceiling: $180 Ossur Formfit Posterior Night Splint Ossur Airform Dorsal Night Splint Darco Dorsal Night Splint

17. Plantar fasciitis: Subsequent Visit Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Severe Aircast SP Walker Ossur Equalizer Low Top Air Walker

18. Posterior Tibialis Tendonitis Possible Diagnosis Codes: 726.72 Tibialis tendonitis 905.8 Late effect of tendon injury, sprain, strain

19. Posterior Tibialis Tendonitis Mild Initial Visit Aircast Airlift PTTD Suggested Code: L1906 DMEPOS Fee Ceiling: $135 PowerStep Insert Suggested Code: L2999 Patient Pays

20. Posterior Tibialis Tendonitis Moderate : Initial Visit Suggested Code: L1971 DMEPOS Fee Ceiling: $505 Ossur Rebound Hinged Ankle Brace Donjoy Velocity ES

21. Posterior Tibial Tendonitis Severe, Initial Visit Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Ossur Rebound Air Walker Ossur Equalizer Premium Air Walker

22. Posterior Tibialis Tendon Rupture Stage 3 Possible Diagnosis Codes: 727.68 Rupture, tendon of foot and ankle, non-traumatic 728.4 Laxity of ligament 734 Flat foot, acquired

23. Posterior Tibialis Tendon Rupture, Stage 3: Initial Visit Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Ossur Rebound Air Walker Ossur Equalizer Premium Air Walker

24. Posterior Tibialis Strain Rupture, Stage 3: Subsequent Visit, if getting better Aircast Airlift PTTD Suggested Code: L1906 DMEPOS Fee Ceiling: $135 Less Severe Donjoy Velocity ES More Severe Ossur Rebound Suggested Code: L1971 DMEPOS Fee Ceiling: $505

25. Posterior Tibialis Tendon Rupture ~ Stage 3: Subsequent Visit, if getting worse Arizona Standard AFO Suggested Codes: L1940, L2330, L2820 DMEPOS Fee Ceiling: $1099 Richie AFO Suggested Codes: L1970, L2820 DMEPOS Fee Ceiling: $901

26. Post Op Bunionectomy, Metatarsal Osteotomy Possible Diagnosis Codes: 825.25 Fracture of the metatarsal bone 719.47 Pain joint, foot

27. Metatarsal Fracture Initial visit Darco Med-Surg Walker Suggested Codes: L2999 DMEPOS Fee Ceiling: Patient pays Ossur Equalizer Premium Low Top Walker Suggested Codes: L4386 DMEPOS Fee Ceiling: $171

28. Pediatric Fracture Possible Diagnosis Codes: 729.5 Ankle pain and support 719.07 Unspecified disorder of ankle and foot 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.01 Sprain and strain of ankle and foot, deltoid ligament 824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar

29. Pediatric Fracture Initial Visit Pneumatic Walker, Pediatric Size Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Ossur Rebound Air Walker Aircast XP Walker

30. Pediatric Fracture Follow up visit, 7 - 9 weeks Aircast Air-Stirrup, pediatric size Suggested Code: L4350 DMEPOS Fee Ceiling: $100

31. Tarsal Tunnel Syndrome Possible Diagnosis Codes: 355.5 Tarsal tunnel syndrome 719.47 Pain in joint, ankle, foot

32. Tarsal Tunnel Syndrome: Initial Visit Mild Moderate Suggested Code: L1971 DMEPOS Fee Ceiling: $505 Ossur Rebound Donjoy Velocity ES Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

33. Severe Tarsal Tunnel Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Aircast SP Walker Ossur Equalizer Low Top Air Walker

34. Severe Tarsal Tunnel Syndrome: Subsequent Visit Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

35. Peroneal Tendonitis Possible Diagnosis Codes: 726.79 Enthesopathy of ankle and tarsus

36. Peroneal Tendonitis Initial Visit Mild to Moderate Ossur Game Day Suggested Code: L1906 DMEPOS Fee Ceiling: $135

37. Peroneal Tendonitis ~ Severe Initial Visit Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Aircast SP Walker Ossur Rebound Air Walker Ossur Equalizer Low Top Air Walker Ossur Equalizer Premium Air Walker

38. Peroneal Tendonitis Subsequent Visit Severe Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

39. Sinus Tarsi Syndrome Possible Diagnosis Codes: 726.79 Enthesopathy of ankle and tarsus 719.47 Pain in joint, ankle, foot

40. Sinus Tarsi Syndrome Initial Visit Mild Moderate Suggested Code: L1971 DMEPOS Fee Ceiling: $505 Ossur Rebound Donjoy Velocity ES Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

41. Sinus Tarsi Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Aircast SP Walker Ossur Equalizer Low Top Air Walker

42. Sinus Tarsi Syndrome ~ Severe Subsequent Visit Ossur GameDay Suggested Code: L1906 DMEPOS Fee Ceiling: $135

43. Achilles Tendonitis Achilles Tendon Rupture Possible Diagnosis Codes: 845.09 Achilles tendon strain, rupture 726.71 Achilles tendonitis

44. Achilles Tendonitis ~ Achilles Tendon Tear Initial Visit Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $312 Ossur Rebound Air Walker Ossur Equalizer Premium Air Walker

45. Achilles Tendonitis ~ Achilles Tendon Tear Follow up visit Bauerfeind Achilleotrain Suggested Code: L2999 DMEPOS Fee Ceiling: Patient pays

46. Metatarsal Fracture Possible Diagnosis Codes: 733.94 Stress fracture, unspecified 825.25 Fracture of the metatarsal bone

47. Metatarsal Fracture : Initial visit Ossur Equalizer Premium Non-Pnematic Low Top Walker Suggested Code: L4386 DMEPOS Fee Ceiling: $171 Darco Med-Surg Walker Suggested Code: L2999 DMEPOS Fee Ceiling: Patient pays

48. Metatarsal Fracture Follow up visit PowerStep ProTech Prefabricated Orthotic Suggested Code: L2999 DMEPOS Fee Ceiling: Patient pays

49. Flaccid Drop Foot Possible Diagnosis Codes: 736.79 Acquired deformity of foot and ankle 438.20 Hemiplegia 719.97 Joint derangement, ankle and foot 356.1 Peroneal muscle atrophy, Charcot Marie Tooth disease 340 Multiple sclerosis 138 Poliomyelitis, late effects

50. Flaccid Drop Foot : Initial Visit Euro International Peromax Suggested Code: L1951 DMEPOS Fee Ceiling: $905 Ossur Dynamic Suggested Code: L1932 DMEPOS Fee Ceiling: $962

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53. 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 2010 HCPCS National Ceiling Fees. ***Not responsible for typographical errors.

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