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Medicare Advisory Specifies A Height Requirement For Custom AFOs

CMS Policy Article, Effective January 2013

Arizona AFO

“Ankle-foot orthoses described by codes L1900, L1910-L1990 extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. The terminal height of an AFO shall be located between the proximal border of the gastrocnemius and the apex of the head of the fibula (a region that is generally 2-4 cm distal to the apex of the head of the fibula). These features distinguish them from foot orthotics which are shoe inserts that do not extend above the ankle and ankle gauntlets described by codes L1902 – L1907.”

http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=47227&ver=32&ContrId=138&ContrVer=1&LCDId=27229&kq=906925540&ua=highwire&IsPopup=y&;

Though not required for custom devices, manufacturers can submit devices to PDAC for verification to determine whether the AFO designs meet Medicare verification requirements.

Arizona AFO, has received HCPCS coding verification for the following products:

Arizona Extended L1960, L2330, L2820
Arizona Partial Foot L1940, L2330, L2820, L5000
Arizona Standard Short L1940, L2330, L2820
Arizona Standard Tall L1940, L2330, L2820
Arizona Unweighting L1960, L2330, L2820
Arizona Breeze L1940, L2330, L2820
Arizona Sporty L1940, L2330, L2820
Arizona Closed Toe Walker L1960, L2330, L2820, L3230, L3400
Arizona Neurowalker L1960, L2330, L2820, L3230, L3400
Moore Balance Brace L1940, L2330, L2820
Open Toe Walker L1960, L2330, L2820, L3230, L3400
Partial Foot Walker L1940, L2330, L2820, L3230, L3400, L5000
Thermoplastic AFO L1960
Thermoplastic Articulated AFO L1970
Thermoplastic Articulated AFO, Dorsi-Assist L1970, L2210
Split Upright AFO L2999
Split Upright AFO, Dorsi-Assist L2999

As stated on the PDAC website, “the assignment of a HCPCS code to the product(s) should in now way be construed as an approval or endorsement of the product(s) by the PDAC, DME MACs or Medicare, nor does it imply or guarantee claim reimbursement.”

The APMA, together with AOPA, is contesting the new definition as it brings into question the appropriateness of billing the popular double upright, hinged type plastic AFO using the L1970 and L2210 codes.

Clarification from the DME MAC medical directors is expected soon.

Taking Over A Practice Which Has An Active DME Number

Question:

My partner’s wife is taking over a practice which has an active DME number with the contact person as the original owner. How difficult is it for her to change the contact person and supplier to herself? Will she be required to submit an entirely new DME application even though the tax ID of the practice will remain the same?

Answer:

Here is the info you need to know.  I’ve included citations to support the recommendations.

A CMS-855S needs to be completed to submit Change of Information.

“Change of Information Other Than Adding a New Location
If you are adding, deleting, or changing information under your current Medicare supplier billing number. Any change to your existing enrollment data must be reported within 30 days of the effective date of the change.”

For Change of Ownership and/or Managing Control there is a section that should be selected.
It directs the supplier as to what sections in the application must be completed:

“Ownership and/or Managing Control Information (Individuals)
1C, 2A1, 3, 6, 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and 6 for the signer if that authorized or delegated official has not been established for this DMEPOS supplier.”

There are a couple things that they should know in completing the form:

Section 2.A.1 – Supplier Identification
This information should identically match the current information that is on file with the National Supplier Clearinghouse.
If it is an Organization, chances are that the same DMEPOS PTAN may be kept.
If the current supplier is a Sole Proprietor, using an EIN with a DBA, chances are that the new supplier will get a new number.

Section 3 – Final Adverse Legal Actions/Convictions
This section MUST be answered “Yes” or “No”.
If the answer is Yes, then “Yes” should be checked and details listed.
If the answer is “No” then they should check off “No” and continue on to the next section.

Section 6 – Ownership Interest and/or Managing Control Information (Individuals)
This page is used to identify the new owner as being added and should be completed in its’ entirety.
New individual information should be added.
Exiting individual should be “Deleted”
PLEASE NOTE: This page needs to be submitted for each individual.  Make copies of this page as needed.

Section 13 – Contact Person
It is always suggested to have someone, other than the supplier, as an additional contact person in case there are questions.

Section 15 – Certification Statement
The application must be signed. Copies or stamps are not acceptable.

Section 17 – Supporting Documents
Copy of your bill of sale if you purchased an existing DMEPOS supplier with an active Medicare supplier billing number.

Please let me know if I can be of further assistance.

Josh

Preventing Amputations Diabetic Foot Risk Assessment

By Robert Frykberg, DPM, MPH
PRESENT RI Editor
Diabetic Limb Salvage

Earlier this year we discussed the importance of the Comprehensive Diabetic Foot Examination (CDFE) as a key component in any diabetic lower extremity amputation prevention program (March 2012). Of course, recognition of the important risk factors for amputation lies at the heart of any screening program and forms the basis for the comprehensive examination.1-4 The CDFE was put forth in an American Diabetes Association (ADA) publication in August of 2008 based on the work of a special task force convened for the purpose.5

As we had previously discussed, the CDFE report highlights the important aspects not only of the patients’ history, but also of the examination of each lower extremity system. Starting initially with general inspection, the basic components of the dermatological, musculoskeletal, neurologic, and vascular systems are illustrated to give the general practitioner an overview of important aspects to consider and findings that can be important risks for ulceration (and consequently amputation). Finally, based on the examination findings, patients can be stratified into levels of risk. Risk assessment becomes important in determining the necessary frequency of care for such patients. In this regard, those found to be at “high risk” for ulceration or recurrent ulceration/amputation will require a higher level of care than those at a low risk for ulceration. The risk assessment tool/classification system is based on one initially proposed by the International Working Group on the Diabetic Foot and has been adopted by most countries around the world for this purpose.6, 7

Risk Category Definition Treatment recommendations Suggested follow-up
0 No LOPS, no PAD, no deformity • Patient education including advise
on appropriate footwear
Annually (by generalist and/or specialist)
1 LOPS ± deformity • Consider prescriptive or
accommodative footwear.
• Consider prophylactic surgery if
deformity is not able to be safely
accommodated in shoes. Continue
patient education.
Every 3-6 months (by generalist and/or specialist)
2 PAD ± LOPS • Consider prescriptive or
accommodative footwear.
• Consider vascular consultation for
combined follow-up.
Every 2-3 months (by specialist)
3 History of ulcer or amputation • Same as category 1
• Consider vascular consultation for
combined follow-up if PAD present.
Every 1-2 months (by specialist)

 

The recommended risk classification adopted by the ADA is shown in the accompanying table. As would be expected, progressive levels of foot pathology are associated with increasing risk levels and associated categories. Although I do not agree with the terminology, Risk Category 0 includes those patients withoutevidence of loss of protective sensation (LOPS), peripheral arterial disease (PAD), or deformity. Nonetheless, I believe that any diabetic patient is potentially at risk for complications, including infection. Those in this category require only preventive education and annual CDFE. They do not generally require referral for specialist care due to their low risk for ulceration. Risk Category 1 includes those patients with neuropathy (LOPS) who may or may not have deformity. As a major risk factor for numerous lower extremity complications, neuropathy itself places the foot at risk. Accordingly, patients in this category should be seen every three to six months for examination and preventive foot care is required. Podiatrist (or other specialist) referral is warranted for such patients. Optimally, prescriptive diabetic footwear including multi-density insoles will be provided as part of a prevention strategy. If deformity is significant (very prominent hammertoes, for instance, with recurrent callus), consideration needs to be given to prophylactic corrective surgery – especially when deformity cannot be easily accommodated in therapeutic footwear commander du cialis sur internet. Take note that we recommended proactive surgical correction as necessary in our recommendations. Patients found to have PAD on examination (with or without LOPS) are assigned the next highest level of risk, that of Risk Category 2 . For obvious reasons, these persons require more frequent evaluation – especially in the presence of neuropathy – and referral to a vascular specialist for advice concerning any necessary diagnostic testing or therapeutic interventions. Such patients are routinely seen by specialists every two to three months for education, examination, preventive care, footwear therapy, etc. The rationale of more frequent visits is to allow for early intervention if new problems should arise. Diabetic patients with a prior history of ulceration, amputation, or Charcot foot are assigned to the high Risk Category 3 . It has been well established that persons with the aforementioned complications are at high risk for future development of ulceration and amputation. Accordingly, such persons require specialist care every one to two months to provide ongoing education, foot care, footwear provision and evaluation, as well as early intervention should new lesions arise. Vascular referral is, of course, required for ischemic complications. Inherent in this guide for ongoing preventive care is the principle that multidisciplinary cooperation is essential, using all necessary specialists to prevent the progression of established complications or to prevent limb loss when patients develop ulceration, infection, or gangrene.

Screening your diabetic patients for lower extremity complications can be a critical step in overall care and can not only save limbs, but improve survival as well. Review the CDFE document referenced below as well as the other references so that you can become familiar with the common risk factors for ulceration and amputation. If not entirely preventable, early and appropriate intervention of new ulcers and infections is surely the best way to avoid lower extremity amputations in our high risk patients with diabetes.

Robert Frykberg, DPM, The VA PACT Experience: Mortality and First Onset Diabetic Ulcer

Robert Frykberg, DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage

References:

  1. Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990; 13: 513-521.
  2. Reiber GE, Vileikyte L, Boyko EJ, et al.: Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999; 22(1): 157-62.
  3. Frykberg RG, Zgonis T, Armstrong DG, et al.: Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision). J Foot Ankle Surg 2006; 45(Suppl): S2-S66.
  4. American Diabetes Association: Consensus Development Conference on Diabetic Foot Wound Care. Diabetes Care 1999; 22(8): 1354.
  5. Boulton AJ, Armstrong DG, Albert SF, et al.: Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008; 31(8): 1679-85.
  6. International working group on the diabetic foot: International Consensus on the Diabetic Foot. In: Apelqvist J, Bakker K, Van Houtum WH, et al., eds., vol 2005. Maastricht: International Working Group on the Diabetic Foot, 1999.
  7. Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC: International consensus and practical guidelines on the management and the prevention of the diabetic foot: International Working Group on the DiabeticnFoot. . Diabete Metab Res Rev 2000; 16 ((Suppl. 22. 1)): S84 –S92.

Doctor Dies Prior to Dispensing DME

Question:

If my doctor passes away before the patient picks up their DME item, would these claims be billed differently than a normal DME claim? My concern is that the date of service, while coinciding with the date of pick-up, will occur after the date of death of the doctor.  Any suggestions?

Answer:

Ancillary personnel cannot dispense DME, just as they cannot bill for surgery that was not performed by the physician who employs them livraison cialis.

If the practice was taken over even temporarily by another physician, (assuming they have a DME number), then that physician could bill for the device as the supplier.

Narrative Required for Not Otherwise Classified HCPCS Codes

Suppliers are asked to include a concise description when billing Not Otherwise Classified (NOC) HCPCS Codes (ie L2999). This information is to be submitted within the Item 19 on the CMS-1500 claim form or the NTE segment in the 2400 loop (line level) for an electronic claim. The following listing of HCPCS has been provided to assist suppliers in proper claim and narrative submission when billing claims to NAS DME Jurisdiction D. Suppliers should remain current with HCPCS updates, Local Coverage Determinations, Policy Articles, CMS requirements, and other information regarding the DMEPOS they provide.

Modifiers and descriptions have been provided as they may be billed with the HCPCS. Any HCPCS below, regardless of the use of a modifier, would require a narrative be submitted with the claim.

HCPCS Modifiers Short Description

L2999 Lower extremity orthosis NOS

Modifier descriptions have been provided as a convenience. Suppliers are encouraged to view the Pricing, Data Analysis and Coding contractor’s website, https://www.dmepdac.com/dmecsapp , for HCPCS and modifier research:

• AV: Item Furnished in Conjunction with a Prosthetic Device, Prosthetic or Orthotic
• KF: Item Designated by FDA as Class III Device
• KO: Single Drug Unit Dose Formulation
• KP: First Drug of a Multiple Drug Unit Dose Formulation
• KQ: Second or Subsequent Drug of a Multiple Drug Unit Dose Formulation
• MS: Six Month Maintenance and Servicing Fee for Reasonable and Necessary Parts and Labor Which are not Covered Under any Manufacturer or Supplier Warranty
• NU: New Equipment
• RR: Rental (Use the ‘RR’ Modifier When DME is to be Rented)
• UE: Used Durable Medical Equipment
Additional situations in which a narrative should be submitted with a claim are accessible from the NAS website,<a href="https://www prix vrai cialis.noridianmedicare.com/dme/claims/cms1500_08-05_instructions.html#19″ target=”_blank”>https://www.noridianmedicare.com/dme/claims/cms1500_08-05_instructions.html#19.

Obtaining Facility Accreditation to Get Paid by Private Insurers for Dispensing DME

Question:

Josh,
My office is currently having problems getting paid by some insurance plans as they question our ability to dispense products. Like you, I graduated from the CCPM School and I believe I have great training in orthotics, AFO, and DME equipment that makes me more qualified than most DME suppliers. The bottom line that most private insurance companies are saying I need to be certified by ABC or another group. Has your office done this and if so what certification organization did you use? Did you get certified as an individual or group? Do you have any recommendations or suggestions that would help?

Answer:

Sorry to hear about your troubles getting qualified to get paid by private insurers for DME.

DSPMs are lucky in that we are exempt from obtaining facility accreditation to get paid for dispensing DME. Non-physician suppliers like orthotists, prosthetists, CPeds, pharmacists are not. They get Facility Accreditation form either BOC or ABC.

DPMs can get facility accreditation and in fact Jonathan had his facility pass the requirements.

Private insurers can make their own rules and so I believe it is legitimate what they are asking of you to be a qualified provider.

Getting facility accreditation for your practice is not that onerous and might be very much worth it for the benefit of providing products to these patients. It might even open the door to other non-accredited providers referring their patients to you. The few DPMs I know who have gone through it have said that the process improved their organization overall.

Below are links and info for the accrediting organizations.

Here is a copy of a presentation I prepared several years ago when it was looking like a Medicare requirement for DPMs:
Basics of Facility Accrediation

As always, SafeStep is here to help.

Best regards,
Josh

Accreditation Links:

http://www.bocusa.org/becoming-accredited

http://www.bocusa.org/files/Facility_Accreditation_Standards.pdf

http://www.abcop.org/accreditation/OrthoticsProsthetics/Documents/ABC-Acc-Standards%209-23-12lores.pdf

http://www.abcop.org/accreditation/FacilityAccreditationFAQ/Pages/Default.aspx

Schedule a FREE Training Session with a SafeStep EXPERT

Schedule a FREE Training Session with a SafeStep EXPERT to Start up a Fall Prevention Program in your Practice

SafeStep Training Sessions are designed to help your practice grow.  Schedule a FREE one-on-one personalized on-line appointment with one of our trained EXPERTS to make fall prevention an important part of your practice.  In one 45-minute session, you will cover:

  • The scope of the problem
  • The role of the podiatrist in preventing falls
  • How to perform a fall risk assessment
  • How the Moore Balance Brace can help
  • Review of MBB models
  • Medicare compliance
  • Steps to integrate fall prevention into your practice

At the conclusion of your session, your EXPERT will:

  • Ensure that your office has patient brochures and posters
  • Order casting kit, casting socks, if needed.
  • Print fall risk assessment, order forms
  • Provide shipping labels.
  • Show where more assistance is available.
  • Schedule a follow-up appointment for additional training.

SafeStep EXPERT Training is intended to help you grow your practice, improve patient care and enhance practice revenue.

Call 866.712.7837 or email us at info@safestep.net to schedule your FREE individualized on-line session!

Register for a free Fall Prevention webinar

Order free Patient Brochures/Office Posters

Let Us Teach You