Archive for Coding
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?
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.
Medicare’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
Medicare 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)
For additional information about the Moore Balance Brace and fall prevention please contact SafeStep at 866.712.STEP (7837) or email firstname.lastname@example.org.
To start off this week, we have a question and answer on Coding and assisted living facilities (ALF). As always, if you have a topic or question you want me to address, please use the contact us button above or visit our new forum to ask your questions.
Question: One of our physicians goes to an adult living facility (ALF) to treat patients. The ALF has an office/clinic area to treat the ALF patients on an appointment basis. Some independent patients walk over to be seen at the ALF clinic by our physician. The doctor codes the “independents” using CPT 9921x E/M service codes.
I am confused about the place of service code for the adult living facility. Our old billing service billed these patients as having being seen at our south office, and not at an ALF facility. While the treatment area in the ALF is an office setting, it is not our office.
‘Assisted Living Facility – Congregate residential facility with self-contained living units providing assessment of each residents needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.”
Answer: This turns on whether the provider is renting or owns the space that patients are being seen in. If renting, it needs to be at fair market value.
If the provider owns or rents the space, then it is considered his/her office, and POS 11 is appropriate.
If she/he were simply using the space as a courtesy from the facility, then a different POS code (other than 11) would be used. If it was an assisted living facility (ALF), it’s important to determine the actual POS designation as possible for 2 or more to be under the same roof.
The difference is that if the office is owned or rented by the provider, Medicare will pay more to help cover overhead costs. If not, then the actual cost of the space (heat, light, capital, etc.) is being paid by the facility so Medicare will not pay as much. Most other payers do not differentiate.
For today’s post, here’s a quick question and answer I wanted to share with you.
I have a patient who is post-base wedge osteotomy for a bunion. I placed her in a CAM walker.
How would one bill this item (i.e., diagnosis code and modifier appended to the CAM walker code)?
An osteotomy is a surgical fracture/incision of bone. The patient, in this case, would therefore eligible under ICD-9 825.25 (fracture of metatarsal bones, closed).
Since we want to provide you with the most effective information, here’s another bit of knowledge I hope you find useful.
Billing for L5000 is independent of diabetes but does require a diagnosis code relating to partial foot amputation (V49.71, Great toe, V49.72, Other toe(s), V49.73, Foot).
Nothing states how much of foot must be gone to justify $450 partial foot prosthesis. My opinion, based on conversations with many others, is that sufficient amount of foot must be missing to adversely affect gait or lead to further deformation of foot and the use of device will improve gait and /or protect the foot.
Only a single L5000 can be ordered at a time. It is expected to be of sufficient quality to be “durable”.
When ordering L5000 in combination with diabetic shoes and inserts, get three custom inserts for non-amputated side and single L5000 for amputation side.
Again in my opinion, proximal TMAs are best fit with high top shoe and probably a custom shoe with a rigid rocker bottom sole.