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.

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.

 

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.