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