Jan
14

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

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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, 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 

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

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Comments

  1. hi josh,
    I am reading this e-mail with some consternation as it relates to the Arizona brace line and the balance brace.
    I received an e-mail from jon moore about 2 weeks ago and he indicated that the MBB would not have problems with the new height requirement.
    Has this information changed?
    If so, are there any changes planned in these braces to meet the new requirements?

    Thanks Josh for your time and info. jd

    • admin says:

      Jim,

      Thanks for commenting. Arizona AFO and every other prefabricated and custom AFO manufacturer are adjusting to the recent Medicare AFO height requirement. Arizona AFO has always had some devices including the Extended model that extend to behind the calf and so qualify. Medicare reimbursable versions of the Standard, the Articulated, the Split Upright Thermoplastic Articulated and the Moore Balance Brace are in the works. Samples will be shown at the SAM conference this weekend and at the NY Clinical Conference next week. The new designs will all feature ease of adjustability for patient comfort while offering the increased stability afforded by the additional height. Increased height does necessitate that patients be casted using the STS Bermuda sock that comes up over the calf. Expect to see pictures of new models and revised order forms next week.
      Josh

  2. JERRY LEFF says:

    JOSH, 2 QUESTIONS REGARDING YOUR POST :

    1) WHICH OF THE L4396 – PLANTAR FASCIA NIGHT SPLINTS- HAVE THE ADUSTABILITY FEATURE WHICH IS NOW REQUIRED, I COULD NOT DISCERN FROM YOUR PRODUCT DESCRIPTIONS

    2) RE THE NEW HEIGHT REQUIREMENT FOR THE MBB, YOU SAID , IT SHOULD STILL BE CODED AS L1940, NOT L1960?

    THNX JERRY LEFF NY NY

    • admin says:

      Jerry,
      1. L4396 Plantar facia night splints featuring “adjustability” as required by the AFO LCD are displayed on the safestep.net product search, on top of the page. While PDAC verification is not required, models featuring adjustability include: Darco Body Armor Dorsal Night Splint, Darco Pneumatic Night Splint, Ossur Exoform Dorsal Night Splint, Ossur Formfit Night Splint, SafeStep DME Posterior Night Splint.
      2. It is expected that the DME MAC will clarify Arizona AFO-type devices as being gauntlets, not AFOs and as such, not subject to the recent height requirement. The Advisory article specifies that such devices are to billed using the codes: L1940, L2330 and L2820.
      Josh

  3. Patricia A. Chapman DPM says:

    Josh,
    Thanks for all your help. When new definitions are given out in NY will you let us know as soon as possible? Also is there any chance they may just give new codes to existing Arizona AFO. Not sure how many patients will say yes to a brace that goes up to knee when it is the ankle I am trying to stabilize. Really do appreciate your help. You have always been such a good source of the correct information.
    Sincerely,
    Patricia A. Chapman DPM

    • admin says:

      Pat,
      Thank you for your kind words.

      It is expected that the DME MACs will clarify the recent AFO height requirement as NOT applying to Arizona AFO-type devices and recognizing the Advisory Article as still applicable. The distinction relates to these devices being recognized by Medicare as gauntlets and not AFOs. As such, the AZ AFO Standard, Sporty, Tall and the Moore Balance Brace can continue to be casted using a mid-calf STS sock and should continue to be billed, as the Advisory directs and PDAC verification affirms, using the codes L1940, L2330, L2820.

      If the DME MACs inform otherwise, I will be sure to provide an update.

      Josh

  4. Patricia A. Chapman DPM says:

    Hi Josh,
    Thanks for your reply. My specific question is now; I have AFOs that would have met the old codes L1040.L2880, L2330 gauntlet AFO and ones that would have meant L1970, L2330, and L2820 articulating AFOs. I think I understand these are still the codes for these devices but will Medicare reimburse me for them. The conference call with Paul and Harry indicated that even though they had a PDAC number it did not mean Medicare would pay. Or is it that if we want to call a new device an AFO, it will have new code, reimburse differently and it will need to include the entire calf. I am still confused sorry. Our state insurance person said I would not be paid for these but he also dispensed non custom orthopedic shoes as custom orthopedic shoes to Medicaid so not sure he understands either. Sorry for being such a pest.

    • Josh White says:

      Pat,

      I anticipate the DME MACs to soon clarify appropriate billing for Arizona AFO-type devices to be L1940, L2330, L2820 as specified by the PDAC Advisory Article. Nothing changes regarding casting, billing and height requirements for Arizona AFO Standard, Tall, Sporty and Moore Balance Brace devices. Custom fabricated, articulated type devices, whether plastic or leather are not considered gauntlets and as such, must meet the height requirement to be billed using the L1970 code. Manufacturers have already come up with a variety of design modifications to enable such devices to be appropriately billed. These L1970 devices all need to be casted to the top of the calf.

      As communicated by the PDAC on January 18th:

      The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have identified Healthcare Common Procedure Coding System (HCPCS) codes where height requirements apply for these types of AFOs.

      If you are creating an AFO under the code of L1940, Ankle Foot Orthosis, Plastic Or Other Material, Custom Fabricated; then the definition shall apply. (The language of “other material” means carbon fiber or other composites materials.)

      • The terminal height of an AFO shall be located between the proximal border of the gastrocnemius and the apex of the head of the fibula (a region that is generally 2-4 cm distal to the apex of the head of the fibula). When making an AFO for the L1940 and other AFO listed within the article, the height requirements shall apply as they have always been at a point distal to the apex of the head of the fibula.

      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.

  5. Patricia A. Chapman DPM says:

    Again thank you so much. I now have a much clearer understanding of the difference between Gauntlet style and AFOs. .As always you have been great.

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