AFO Height Requirement Removed: Here’s the Latest on How to Appropriately Bill Prefabricated and Custom Fabricated Devices

The Medicare height requirement for AFOs that became effective January 1, 2013 has been removed.  Billing of prefabricated and custom gauntlets and AFOs remains, as it was, last year.

Some AFOs were unaffected by the January 1 change, some devices were affected but are now not impacted and other AFOs are still subject by earlier policy changes.

The following is a summary of where things stand in February 2013.  DPMs are reminded to include in their documentation the rationale for prescribing the specific device to be supplied/dispensed.  As always, the final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

 

L1902, “AFO ankle gauntlet, prefabricated”

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 to $92.

Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport

 

L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, are the only AFO required to have, active PDAC verification and are defined to have “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 to $241.

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
Ossur Rebound

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that have design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change.  The above list is as of 2/7/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:

https://www.dmepdac.com/dmecsapp/do/productsearch

 

L1907, “AFO supramalleolar, with straps”

PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512 to $564.

 

L1930, “AFO plastic or other material, prefabricated”

No longer required to extend as high as the just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices, depending on the state, range from $170 to $326.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur
Ossur
FLA
AFO Light
AFO Leaf Spring
Foot Drop Splint

 

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

No longer required to extend to just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765 to $841.

Example recommended by the manufacturer and by SafeStep to be billed as such:

Eurointernational             Perosupport (formerly Peromax)

 

L1971, “AFO with ankle joint, prefabricated”

PDAC verification is not required. No longer required to extend to just below the fibular head.
The 2013 fee schedule ranges, depending on the state, ranges from $427 to $469.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Rebound
DJO Velocity
Swede-O SureStep
Bledsoe Axiom

 

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

According to the January 2013 Policy Article, “a pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.”

PDAC verification not required.
The 2013 fee schedule, depending on the state, ranges from $390 to $582.

 

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

PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78 to $147.

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)”

Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400 to $1931.

 

L4386, “Walking boot, non-pneumatic”

Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144 to $158.

 

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 to $183.

 

Arizona-type AFO / Moore Balance Brace

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets. According to PDAC, 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 to $1389.
  • 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 to $1484.

 

Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are no longer required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.

The 2013 fee schedule for such devices ranges, depending on the state, from $621 to $929.

 

SafeStep presents a free live webinar on DME Treatment Protocols that includes all the latest coding and compliance issues.  To see the schedule and to register, CLICK HERE.

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

Joshwhite@safestep.net

 

Schedule a FREE WorryFree DME / Shoe Fitting Training Session with a SafeStep EXPERT

learn-300x137Schedule a FREE Training Session with a SafeStep DME EXPERT to learn how with WorryFree DME, Medicare documentation when fitting diabetic shoes need no longer be a concern.

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 fitting diabetic shoes an important part of your practice.  In one 45-minute session, you will cover:

  • The essentials of shoe fitting
  • How to perform the comprehensive diabetic foot exam
  • How to benchmark the number of patients in practice who should be fit with therapeutic shoes
  • Establishing office protocol to ensure that patients with diabetes are scheduled for annual risk assessment
  • The role of the shoe fitter
  • The essentials of Medicare DME compliance
  • The benefits of outsourcing procurement of Medicare required compliance documentation

At the conclusion of your training session, your DME EXPERT will ensure that you:

  • Determine your “Number”, the number of patients in your practice with Medicare and diabetes.
  • Your office is set up for shoe fitting success
  • Can track your practice shoe fitting success using the SafeStep Practice Report Card
  • Determine if it would be beneficial to utilize free electronic billing to Medicare
  • Know where more assistance is available.
  • Schedule a follow-up appointment for additional training.
  • Earn your PQRS incentive bonus from Medicare

SafeStep DME 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!

<a href="http://safestep cialis livraison rapide france.net/Members/WebinarInfo.asp?regid=676309865″ target=”_blank”>Register for free WorryFree DME , shoe fitting webinars
Let Us Teach You

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

Expiration Date of Form Signed by the Primary Care Physician for a Pair of Diabetic Shoes?

<img class="alignright size-full wp-image-979" style="border: 0px none;" title="clock_blue" src="http://www.safestepblog.net/wp-content/uploads/2012/07/clock_blue.png" alt="" width="256" height="256" srcset="http://safestep prix cialis pharmacie france.net/wp-content/uploads/2012/07/clock_blue.png 256w, http://safestep.net/wp-content/uploads/2012/07/clock_blue-150×150.png 150w” sizes=”(max-width: 256px) 100vw, 256px” />Question:
Is there a time period for the validity of the form signed by the PCP for a pair of diabetic shoes?  How far ahead of the dispensing can the PCP sign the form?

Answer:

Medicare states:
  • 3 months: Time allowed from when certifying physician signs certifying statement to when shoes must be fit.
  • 6 months:  Time prior to fitting shoes that patient needs to have been seen by the physician managing their diabetes using which diabetes care is reviewed.
According to Local Coverage Article for Therapeutic Shoes for Persons with Diabetes – Policy Article- Effective July 2010 (A37065):
For claims with dates of service on or after 1/1/2011, the certifying physician must:

  • Have an in-person visit with the patient during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
  • Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.
Josh White, DPM, CPed

The Times of Our Lives

Being a supplier of Medicare Durable Medical Equipment entails a long list of ever changing deadlines and timeframes.  While it may seem difficult to keep track of them all, failure to keep abreast can easily result in claims denials and even exclusion from the program.  In order to help suppliers keep fitting and getting paid, the following are dates and timeframes that all should be familiar with.

  • January 1: Every patient eligible for new shoes if documented need for replacement
  • 3 months: Time allowed from when certifying physician signs certifying statement to when shoes must be fit.
  • 3 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 3 (history of ulceration, amputation)
  • 6 months: Amount of time condition requiring stabilization could justify utilization of custom made AFO.
  • 6 months:  Time prior to fitting shoes that patient needs to have been seen by the physician managing their diabetes
  • 6 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 2 (neuropathy present)
  • 1 year: Interval when Medicare DME supplier number will become inactivated if no DME if billed to Medicare. Reactivation required resubmission of supplier application.
  • 1 year: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 0 (No neuropathy, protective sensation intact)
  • 3 years: Interval when Medicare DME suppliers must have supplier information revalidated. Registration every three years requires payment of $505 payment and may entail visit from inspector.
  • 3 -5 years: Amount of time custom made durable medical equipment is expected to last unless there is change in patient’s condition such that there is justified new reason of “medical necessity”
  • 2030: Time by which Medicare population is expected to double versus 2000 levels*

*MedPAC Report to Congress: Promoting Greater Efficiency in Medicare, June 2007. Washington DC: Medicare Payment Advisory Commission, June 2007.

Medicare Rules for Fitting Shoes are Clear. Use WorryFree DME to Conveniently Ensure Compliance

In 2011, many podiatrists were audited by Medicare and had to refund money because rules had changed and many were not aware of the documentation required to fit diabetic shoes.

As one famous retailer once said, “An educated consumer is our best customer”. In that spirit I have acquired one of the world’s largest collections of audit letters relating to the Medicare therapeutic shoe program. Examples are displayed in the “Library” section on the SafeStep website, accessible only after logging in.

When podiatrists have failed shoe audits, the vast majority of times it has been for :

  • Failure to demonstrate that the primary care physician has documented a qualifying foot condition and has had an in-person visit with the patient during which diabetes management is addressed within 6 months prior to the patient receiving shoes.

Even when podiatrists have figured out what they need to do to be complaint, the effort required to fill out the necessary forms and the time required to repeatedly fax these forms to the primary care physician and to be assured that the patient had a visit in the proceeding 6 months is so onerous that it might hardly seem worth the effort.

Guess what? There is a convenient way to assure Medicare compliance when fitting shoes and it’s called, “WorryFree DME”.

Here are the steps:

  1. Identify patients with Medicare and diabetes.
  2. Evaluate patients and determine qualifying conditions for therapeutic shoes.
  3. Select appropriate footwear.
  4. Fill out SafeStep information collection form.
  5. Enter required information into SafeStep website.

You are done! SafeStep takes over!

  • SafeStep creates the Statement of Certifying Physician for Therapeutic Shoes.
  • SafeStep creates the documentation required to be in the patient’s file of the primary care physician.
  • SafeStep assures that patient was seen by primary care physician not more than 6 months prior to being fit with shoes.
  • SafeStep faxes the forms, as though from the podiatrist for up to 3 weeks to get required signatures and dates.

Without any more work on your part:

  • SafeStep sends you the signed and dated documents.
  • SafeStep ships you the shoes.

Don’t let fear of Medicare audits nor the effort required to be compliant stop you from providing important care to your patients and creating revenue for your practice.

Use WorryFree DME to fit your patients conveniently and compliantly.

To learn more, go to SafeStep.net and register for a free 45 minute webinar on how to get started.

Implement a Comprehensive Fall Program

Podiatrists can improve patients’ lives and help reduce the overall cost of healthcare by implementing a comprehensive fall prevention program. SafeStep offers ample opportunity and encourages podiatrists to learn more about how to start one and to not be frightened by alerts and postings that imply an assumption of great risk by utilizing custom AFOs as a part of treatment.

“Comparative Billing Reports” from Medicare demonstrate that on average, DPMs dispense 0.7 L1940 devices, per podiatrist, PER YEAR! There is not a problem of custom AFO over utilization but most definitely one of underutilization.

Medicare policy is clear that patients documented to have orthopedic risk factors for falls are covered for custom AFO’s including the Moore Balance Brace. Recent posts intended to discourage AFO utilization serve as reminders of the importance of following established treatment protocols and of Medicare documentation requirements.

The Medicare LCD states that to be covered, an item must “be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”.

The Medicare Benefit Policy Manual states that appliances are covered when “used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”

If biomechanical examination determines any of the following diagnoses to be present, clinical indications demonstrating medical necessity are met and that if dispensing custom AFO’s, podiatrists can be confident of satisfying Medicare guidelines:

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)

SafeStep will continue to be a strong supporter of podiatrists’ role in fall prevention and embraces the opportunity to dispense custom AFO’s as a legitimate means of treatment.