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Medicare DME Reimbursement for 2016

On October 1, 2016, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs was revised .

While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:,

Depth Shoes (A5500) $140.58
Prefabricated, Heat Molded Inserts (A5512) $57.34
Custom Molded Inserts (A5513) $85.58
Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $312.60
Depth Shoes w/ 3 pr. Custom Molded Inserts $397.32
Custom Molded Shoes w/ offset heels and rocker bottoms $628.96
Arizona AFO, Standard (L1940, L2330, L2820) $1,157.69
Moore Balance Brace (L1940, L2330, L2820) $1,157.69
For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME16-D.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same.  For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

What is the Difference Between the PDAC and the DME MACs?

Function of the PDAC

One function of the Pricing Data Analysis and Coding Contractor is to determine an appropriate Healthcare Common Procedure Coding System (HCPCS) code to use when submitting claims to Medicare. A HCPCS code identifies the durable medical equipment, prosthetics, orthotics, and/or supplies (DMEPOS) being billed.

PDAC Responsibilities

  • Operate a Contact Center to provide coding advice and guidance
  • Maintain DMECS, a web-based interactive tool that provides HCPCS coding assistance and national fee schedule information
  • Respond to written inquiries requesting HCPCS coding assistance
  • Coordinate and participate in requests for HCPCS Coding Verification Reviews
  • Maintain a NDC/HCPCS crosswalk applicable for DME MAC billing

Who is Calling the PDAC?

  • Suppliers
  • Manufacturers
  • Distributors
  • OIG (Office of Inspector General)
  • CMS (Centers for Medicare & Medicaid Services)
  • Consultants
  • Attorneys
  • Doctor Offices
  • Pharmacies
  • Billing Services
  • Other Insurance Carriers
  • DME MACS
  • Medicaid
  • Attorney General Office

PDAC Can:

  • Provide HCPCS coding determinations
  • Provide allowables for items that are on the DMEPOS Fee Schedule

PDAC Cannot:

  • Provide codes for items that are not billable to the DME MACS
  • Answer coverage or policy questions including the use of modifiers
  • Address claim inquiries
  • Provide beneficiary eligibility
  • Assist with questions concerning claim form(s)
  • Address required documentation for claims submission
  • Provide allowables for items that are not on the DMEPOS Fee Schedule
  • Provide publications such as the Supplier Manual, bulletins or DMEPOS Fee Schedules
  • Address CMN or DIF Information
  • Assist with Type of Service or Place of Service codes
  • Provide Diagnosis Codes

Type of Calls Referred to the DME MAC:

  • Coverage and Utilization Questions
  • Eligibility
  • Claim Inquiries
  • Claim Form(s)
  • Required Documentation
  • Allowables for items priced by reasonable charge and individually considered items
  • Publications: Supplier Manual, bulletins and Fee Schedules
  • CMN/DIF Information
  • Type of Service and Place of Service Codes

Results of Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4360, L1970 and L1960)

Review Results

Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of HCPCS codes L4360, L1970 and L1960. This review was initiated based on CERT analysis.

The L4360 review involved 101 claims of which 97 were denied. This resulted in an overall error rate of 97%.

The L1970 review involved 100 claims of which 80 were denied. This resulted in an overall error rate of 79%.

The L1960 review involved 100 claims of which 69 were denied. This resulted in an overall error rate of 68%.

Primary documentation errors that resulted in denial of claims

• 21% of L4360 claims received a denial as basic coverage criteria not met.

• 21% of L1970 claims received a denial as basic coverage criteria not met.

• 30% of L1960 claims received a denial as basic coverage criteria not met.

Medical records are insufficient to support basic coverage criteria.

BASIC COVERAGE CRITERIA: Ankle-foot orthoses are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

•  21% of L1970 claims received a denial as criteria 1,2,3,4 or 5 not met.

•  32% of L1960 claims received a denial as criteria 1,2,3,4 or 5 not met.

1 of the 5 following criteria were not met:

•  The beneficiary could not be fit with a prefabricated AFO; or

•  The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

•  There is a need to control the knee, ankle or foot in more than one plane; or

•  The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

• The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.

20% of L4360 claims received a denial as no proof of delivery submitted.

7% of L1960 claims received a denial as no proof of delivery submitted.

No proof of delivery submitted.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

• 42% of L4360 claims received a denial as no written or verbal order received.

• 7% of L1970 claims received a denial as no written or verbal order received.

• 5% of L1960 claims received a denial as no written or verbal order received.

No written or verbal order received.

All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary’s name

• Prescribing Physician’s name

• Date of the order and the start date, if the start date is different from the date of the order

• Physician signature (if a written order) or supplier signature (if verbal order)

 

For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and start date, if start date different than date of order

• Detailed description of the item(s)

• Physician signature and signature date

Going Forward

Based on high error rate, Noridian Administration Services will close this probe review and begin a widespread targeted review on HCPCS codes L4360, L1970 and L1960.

To review entire article please click here

Implications of the New Medicare AFO Reimbursement Policy and Suggestions How to Appropriately Bill Prefabricated and Custom Fabricated Devices

New Medicare reimbursement policy requires prefabricated and custom AFOs coded as L1900 and between L1910 and L1990 to extend to 4 cm below the fibular head. Established policy also requires L1906 devices to have effective PDAC verification.

http://www.cms.gov/medicare-coverage-database/details/article-details…

Some commonly used AFOs are unaffected by this change, some AFOs should be coded differently, some AFOs are being developed to comply with the new changes and some AFOs no longer qualify for reimbursement.

The following is a review of commonly used prefabricated and custom AFOs with suggestions how to appropriately code in light of these recent changes.

L1902, “AFO ankle gauntlet, prefabricated”
Unaffected by the new policy.
Not required to have PDAC verification nor need extend as high as to near the fibular head.
The 2013 fee schedule ranges, depending on the state, from $69.69 to $92.92.
Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Bledsoe Axiom
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport
Swede-O Ankle-Lok, Step Smart


L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, have been required to have, active PDAC verification, “a hinged ankle and a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation.”.
The 2013 fee schedule ranges, depending on the state, from $104.99 to $241.94.
Examples of such devices with active PDAC verification include:

Darco Body Armor Vario
Medspec EVO Hinge
Swede-O Arch Lok, Atom, Dorsi-Assist
United Surgical Trailblazer Hinged Ankle

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that could has design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change. Products which have not received coding verification from the PDAC must be billed using code A9270, “non-covered item or service”. The above list is as of 1/13/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:
https://www.dmepdac.com/dmecsapp/do/product search


L1907, “AFO supramalleolar, with straps”

Custom fabricated and not required to extend as high as required by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512.77 to $564.06.


L1930, “AFO plastic or other material, prefabricated”

Required to extend as high as specified by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $170.94 to $326.70.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur AFO Light


L1951, “AFO, spiral plastic or other material, prefabricated”

Required to extend as high as specified by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765.34 to $841.84.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Eurointernational             Perosupport (formerly Peromax)


L1971, “AFO with ankle joint, prefabricated”

Required to extend as high as near to the fibular head.  If not, no longer qualify as Medicare reimbursable. Some, like the Swede-O SureStep, though still listed on the PDAC website as L1971, because they do not meet the height requirement, should no longer be billed as such. Some like the Ossur Rebound and the Donjoy Velocity, while lacking PDAC verification, had been recommended by the manufacturer and by SafeStep, prior to January 1, 2013, to be billed as L1971. They should no longer be billed as such. Manufacturers are submitting these devices to PDAC to determine their qualification for L1906 verification. If so, and only then, would they qualify for Medicare reimbursement as such.


L2340, “pre-tibial shell, molded to patient model”

According to the January 2013 Policy Article, “Must extend to between the tibial tuberosity and to within 3 inches of the medial malleolus”.
As a custom item, it “involves substantial work such as cutting, bending, molding, sewing, etc. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item”.
PDAC verification not required.
The 2013 fee schedule ranges, depending on the state, ranges from $390.10 to $582.88


L4350, “ankle control orthosis, stirrup style, rigid”

Not required to extend as high as the knee.
PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78.04 to $147.33.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Formfit, Airform Universal
Aircast Airlift PTTD, Airsport, Air Stirrup
SafeStep DME Air Stirrup, Foam Stirrup
Swede-O Versi-Splint


L4361, “AFO walking boot type, varus / valgus correction (CROW)”

Not required to extend as high as the knee.
PDAC verification is not required. Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400.89 to $1931.59.


L4386, “Walking boot, non-pneumatic”

Not required to extend as high as the knee.
PDAC verification is not required.
Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144.49 to $158.95.


L4396, “static or dynamic AFO including soft interface, adjustable for fit, for positioning, minimal ambulation, prefabricated”

(Plantar fascia night splints)
Must as of 1/1/10 have adjustability. Many dorsal night splints commonly billed using this code lack “adjustably for fit” and so do not qualify for Medicare reimbursement. This item is an exception in that while others AFOs need be for ambulation, L4396 needs not when used for treatment of plantar fasciitis (728.71) or as part of a treatment plan for plantar flexion contracture of 10 degrees or greater (718.47).
The 2013 fee schedule ranges, depending on the state, from $150.37 to $183.51.


Arizona-type AFO

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets and as such, the Medicare DME MAC AFO redefinition for billing such devices DOES NOT require them to reach the new height requirement. According to PDAC:

If you are supplying an Arizona Style Ankle Gauntlet, then the PDAC coding article applies and the device can be delivered as an Arizona Style Gauntlet. The confusion takes place in the nomenclature and descriptor of the ankle gauntlets. These ankle gauntlets are listed in many coding materials as: AFO Ankle Gauntlet, giving way to many thinking these are AFO’s when they are truly ankle gauntlets. The classification and listing language are merely for reference and not indicative of their true functional purpose: the ankle joint complex.

The manufactures have read into the definition and not fully understood that an AFO is well defined and should be followed when supplying one of these orthotic devices. The PDAC advisory article: Ankle-Foot Orthoses – Arizona-Type – Correct coding – Revised<https://www.dmepdac.com/resources/articles/2011/11_15_11.html>, applies when delivering an Arizona type AFO.

Should you need any further assistance please call the PDAC Contact Center at 877-735-1326. Hours of operation are Monday through Friday, 8:30 a.m. to 4 p.m. CT.

PDAC
www.dmepdac.com<http://www.dmepdac.com/> 

According to the PDAC Advisory Article, Arizona Short and Arizona Tall, or similar custom fabricated braces (including the Moore Balance Brace), only the following codes should be used:
L1940 Ankle foot orthosis, plastic or other material, custom fabricated
L2330 Addition to lower extremity, lacer or Velcro closure, molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
The 2013 fee schedule ranges, depending on the state, from $850.37 to $1389.58.

For the Arizona Extended and the Arizona Unweighting or similar custom fabricated braces, only the following codes should be used:
L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
The 2013 fee schedule ranges, depending on the state, from $902.52 to $1484.25.


Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are as of 1/1/13, according to the new AFO Policy Article, required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.
AFO manufacturers, including Arizona AFO have old and are developing new, models that qualify for reimbursement.  Compliance requires that higher devices be casted for up to the knee.

Examples of these devices will be shown at the SAM and NY Clinical Conferences.
The 2013 fee schedule for such devices ranges, depending on the state, from $621.03 to $929.37.
APMA, the American Orthotics and Prosthetics Association and others continue in their efforts lower the new AFO height requirement to a scientifically justified level as well as to allow the Arizona AFO-type Policy Article provide qualification for reimbursement.

The final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

Your comments are welcome and appreciated. Updates relating to this and other coding, billing and compliance issues will be posted on the SafeStep blog, www.safestepblog.net.

Josh White, DPM, CPed

Arizona AFO Coding Guidelines

There has been some confusion and misunderstanding lately regarding Medicare requirements for the proximal height of custom molded AFOs. We want to assure you that when billing for an Arizona AFO that the Medicare Pricing, Data Analysis and Coding (PDAC) Advisory Article, dated 11/22/11 https://www.dmepdac.com/resources/articles/2011/11_15_11.html, is still in effect and the coding stated should continue to be used for 2013.

The management of Arizona AFO, Inc. has personally spoken with the coding expert at the PDAC. He stated that this advisory article is in effect and that when billing an Arizona AFO, providers should continue to follow those guidelines.  He emphasized that if an AFO does not have PDAC assigned coding then it must meet the new height definition.

PDAC assigned coding is important and that is why Arizona AFO went through the process of having it’s products evaluated so that you may code with confidence.

Here is link to all AZ AFO products that have PDAC assigned codes. Enter “Arizona AFO” as the manufacturer: https://www.dmepdac.com/dmecsapp/do/productsearch.

Thank you for your business and for your continued trust in our company and our products! We look forward to serving you and your patients with quality service and products for many years to come.

Best regards,

Josh White, DPM, CPed
President / Founder
SafeStep, LLC

Medicare Rules and Coding for Diabetic Patient with Amputation

Question:
For Diabetic patient with amputation, if requirements are met documentation-wise, are patients entitled to ONE pair of shoes, and diabetic orthotics with met/toe fillers per ONE  year? And what codes would be billed?

Answer:
According to NHIC DME MAC A Listserve of June 8, 2012 featured below, Medicare clarified eligibility for L5000, “Partial foot with longitudinal arch, toe filler”.

If foot missing hallux or forefoot, arch support with filler understood to require additional rigidity than foot insert without filler and can be billed as L5000. Medicare allows coverage for a single L5000. If patient has diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts.

If foot missing lesser digit, arch support with filler NOT assumed to require additional rigidity than foot insert without filler and CANOT be billed as L5000. If patient HAS diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts. If patient DOES NOT have diabetes, “partial foot, shoe insert with longitudinal arch, toe filler” can be billed as L5000 only if beneficiary missing hallux or forefoot. It is not appropriate to billing either L5000, A5512 or A5513 is patient does not have diabetes and is missing lesser digit only.

Toe Fillers and Diabetic Shoe Inserts – Coding Clarification

Questions have arisen about the correct coding for shoe inserts used to accommodate missing digits (toes) on feet for beneficiaries with and without diabetes. These items fall under two separate benefit categories and use two distinct Healthcare Common Procedure Coding System (HCPCS) codes, L5000 and A5513.

Beneficiaries without Diabetes
Shoe inserts for beneficiaries with missing toes or partial foot amputations who are not diabetic are considered for coverage under the prosthetic benefit. Code L5000 is described by:

L5000 – PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER

As noted in the descriptor, code L5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe), or the forefoot, L5000 inserts are designed to provide standing balance and toe off support for improved gait. The biomechanical control required of L5000 differs from the foot-protective function provided by inserts used as part of diabetes management.

For beneficiaries who are non-diabetic and require accommodation of missing foot digit(s) or forefoot, suppliers must only bill code L5000. Codes A5512 and A5513 describe inserts used with therapeutic shoes provided to persons with diabetes (see below) and must not be billed for non-diabetic beneficiaries.


A separate benefit category allows Medicare coverage of therapeutic shoes and inserts for persons with diabetes. Shoe inserts for persons with diabetes are described by the codes below:

A5512 – FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OF SHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER), PREFABRICATED, EACH

A5513 – FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT’S FOOT, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH

For a beneficiary with diabetes missing digit(s) or a forefoot, suppliers have two options for billing inserts:

Option 1: For diabetic beneficiaries who do not require the rigidity and support afforded by code L5000 (e.g., beneficiaries missing digits excluding the hallux), suppliers must bill code A5513 for an insert appropriately custom-fabricated to accommodate the missing digit(s). Codes L5000 or A5512 may not be billed in addition to code A5513.

Option 2: For beneficiaries missing the hallux or a forefoot that require rigidity and support for effective gait, suppliers must bill L5000 for an insert appropriately custom-fabricated to accommodate the missing digit(s) or forefoot as well as providing the foot-protective functions required for a person with diabetes. Codes A5512 or A5513 may not be billed in addition to code L5000.

Suppliers are encouraged to review both the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination and related Policy Article and the Lower Limb Prostheses Local Coverage Determination and related Policy Article for additional information on the coverage, coding and documentation of these items.

The Medicare LCD for therapeutic shoes states that patients with diabetes and ulcerative risk factors may be eligible for a replacement pair of shoes each calendar year.

According to the LCD for lower limb prostheses, Policy Article, Effect January 2011, Replacement of a prosthesis or prosthetic component is covered if the treating physician orders a replacement device or part because of any of the following:

A change in the physiological condition of the patient; or
Irreparable wear of the device or a part of the device; or
The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of the part being replaced.

Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be reimbursed without a physician’s order when it is determined that the prosthesis as originally ordered still fills the patient’s medical needs.

Coding Alert!

Moore Balance BraceMedicare’s Pricing, Data Analysis and Coding (PDAC) has revised it’s original review of the Moore Balance Brace and determined the HCPCS codes to use for billing to be:

  • L1940 – ankle foot orthosis, molded to patient, plastic
  • L2820 – addition to lower extremity orthoss, soft interface for molded plastic, below knee section
  • L2330 – addition to lower extremity orthosis, lacer molded to patient model, for custom fabricated orthoses only.

The 2012 maximum allowable fees for these codes are:

  • L1940 $571.10
  • L2820 $100.28
  • L2330 $453.44

PDACMedicare fees vary by state so go to www.dmepdac.com to determine the specific allowable amounts for your patients.

The Moore Balance Brace is commonly prescribed bilaterally to address risk factors contributory to increased risk of falling. Frequently determined diagnoses that might benefit from the stability afforded by the MBB include:

  • Muscle weakness (728.87)
  • Ataxia, muscular incoordination (781.3)
  • Gait abnormality/ staggering, ataxic (781.2)
  • Osteoarthritis, localized primary ankle & foot (715.17)
  • Arthropathy, unspecified, ankle and foot (716.97)
  • Pain in joint, ankle, foot (719.47)
  • Instability of joint, ankle & foot (718.87)
  • Dropfoot (736.79)
  • Hemiplegia (438.20)

Click Here for information on how you can incorporate a fall prevention program in your practice, or register for a free informational webinar!

For additional information about the Moore Balance Brace and fall prevention please contact SafeStep at 866.712.STEP (7837) or email info@safestep.net.

PDAC Certification Letter

Moore Balance Brace Receives Medicare PDAC Coding Verification

Medicare’s Pricing, Data Analysis and Coding (PDAC) has determined that the HCPCS codes to use when billing the Moore Balance Brace are :

  • L1940 – ankle foot orthosis, molded to patient, plastic
  • L2820 – addition to lower extremity orthoses, soft interface for molded plastic, below knee section

The 2012 maximum allowable fees for these codes are:

  • L1940 $571.10
  • L2820 $100.28

The Moore Balance Brace is commonly prescribed bilaterally to address risk factors contributory to increased risk of falling.

Frequently determined diagnoses related to increased risk for falling that might benefit from the stability afforded by the MBB include:

  • Muscle weakness (728.87)
  • Ataxia, muscular incoordination (781.3)
  • Gait abnormality/ staggering, ataxic (781.2)
  • Osteoarthritis, localized primary ankle & foot (715.17)
  • Arthropathy, unspecified, ankle and foot (716.97)
  • Pain in joint, ankle, foot (719.47)
  • Instability of joint, ankle & foot (718.87)
  • Dropfoot (736.79)
  • Hemiplegia (438.20)

Arizona AFO, the manufacturer of the Moore Balance Brace believes that like it’s other gauntlet devices, the MBB should also be verified for HCPCS code L2330, with the comment, “used whether the closure is a lacer closure or a Velcro closure” and has scheduled an in-person appeal in Fargo, ND in April.

Suppliers are advised that until the PDAC reconsiders the verification determination that only codes L1940 and L2820 be used for billing purposes.

For additional information about the Moore Balance Brace or fall prevention please see the SafeStep forum (safestepforum.net), blog (safestepblog.net) or contact SafeStep at 866.712.STEP (7837) or email info@safestep.net.