Making the use of DME and the Medicare Therapeutic Shoe Program easier.
Customer LoginMedicare 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.
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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.
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.
The 2012 maximum allowable fees for these codes are:
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:
For additional information about the Moore Balance Brace and fall prevention please contact SafeStep at 866.712.STEP (7837) or email info@safestep.net.
Medicare’s Pricing, Data Analysis and Coding (PDAC) has determined that the HCPCS codes to use when billing the Moore Balance Brace are :
The 2012 maximum allowable fees for these codes are:
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:
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.
Medicare recently announced that the design of an L1906, multi ligamentous ankle support must “include a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation” and that devices that meet the description are now required to have a PDAC verification letter. See the full descriptions below:
We have received updated HCPCS Coding Verification letters on both the Swede-O Arch Lok and Atom Hinged Ankle braces.
Notifications on other devices in this category will be forthcoming as they become available.
Until March 31, 2012, a PDAC verification letter has not been required for a device to qualify for Medicare reimbursement. It has simply been necessary that the device meet the description described below:
L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTOUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
A multiligamentous ankle support provides control of the ankle joint between the medial and lateral malleoli while allowing for dorsiflexion and plantar flexion. This off-the-shelf ankle support includes a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation. This, in conjunction with wrap-around straps and the inherent gauntlet design, offers areas of multiligamentous support as described by the code. There are no additional HCPCS codes for this type of prefabricated ankle orthosis.
Additionally, Medicare said
Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 (ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT) are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification Matrix of the DME Coding System (DMECS). Products which have not received coding verification review from the PDAC must be billed with code A9270. Please refer to the advisory article titled Coding Guidelines for Ankle Foot Orthoses.
Products that are currently listed on DMECS with L1906 will be end dated effective March 31, 2012 and changed to A9270 until a coding verification review has been completed by the PDAC.
Thus, it is mandatory that manufacturers submit to PDAC devices for L1906 verification in order for them to qualify for reimbursement.
There are some multi ligamentous type devices that have been recommended to be billed using L1906 code such as the Ossur Exoform and the GameDay that do not have a foot plate. As such they would need to be billed as A9270. They might more appropriately meet the description of L1902. See description below:
L1902 ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
The Donjoy Velocity (and Ossur Rebound) are recommended by the manufacturers to be billed using code L1971. This is based on the description below:
L1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
For a complete list of products that are currently listed on PDAC site with L1906 code see the link below:
https://www.dmepdac.com/dmecsapp/do/productsearch
In summary, the new ruling affects items billed using L1906 not L1971. Some items currently filed as L1906 will need to be reclassified as L1902. All items that meet new definition of L1906 will need a verification letter starting April 1, 2012.