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THE PODIATRIST’S GUIDE TO

MEDICARE BILLING FOR

CUSTOM FABRICATED

ANKLE-FOOT ORTHOSES
Introduction:

Medicare (and most insurance carriers) provides coverage for custom-


molded ankle-foot orthoses (AFO’s) when deemed reasonable and
necessary for the treatment of certain lower extremity conditions. These
devices are a covered benefit when prescribed for the purpose of
supporting a weak or deformed body member or to restrict or eliminate
motion in a diseased or injured part of body. Designed to improve
function in patients with certain lower extremity conditions, custom
molded AFO’s can help prevent suffering and control further progression
of deformities. In order to be reimbursed by Medicare and other
insurance carriers for fitting and dispensing custom molded AFO’s,
certain criteria must be met. Once these criteria have been met, it is
important that billing is done properly so that you will be correctly
reimbursed. The information in this manual is designed to assist you in
navigating your way through this process--a process, incidentally, which
few podiatrists take advantage of. Nonetheless, as you will see, once the
practitioner takes the time to understand and learn the billing process, the
revenue stream created by prescribing custom molded AFO’s is well
worth the effort.

Why should podiatrists prescribe AFO’s?

As foot and ankle surgeons, podiatrists should be knowledgeable


regarding those foot, ankle and leg conditions amenable to conservative
treatment using an ankle foot orthosis (AFO). Podiatrists are intimately
familiar with prescribing orthotic devices to control foot function but,
until recently, most podiatrists have been reluctant to prescribe and
dispense AFO’s even though they often diagnosis and manage the
conditions for which these devices are warranted. Traditionally, once the
diagnosis is made, the patient is often referred out to a local orthotist or
prosthetist for the fabrication and dispensing of the device. In many of
these cases, the results may be less then desirable due to lack of
communication between the podiatrist and the specialist fabricating the
orthosis regarding the special requirements of the individual patient. There
is, however, a growing trend whereby more and more podiatrists prescribe
and dispense these devices. They understand the wide applicability of
orthoses as a definitive treatment modality as well as an adjunct to
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surgery. Podiatrists can and should provide this necessary service just as
they provide and dispense functional foot orthotic devices. Furthermore,
although most insurance companies do not reimburse payment for a
custom foot orthosis, they will, generally speaking, provide payment for
AFO’s as a covered benefit for appropriate conditions.

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THE ECONOMICS OF PRESCRIBING CUSTOM AFO’S

As a podiatrist, you are in a unique situation. As a prescribing doctor and


supplier, you can bill for virtually all services connected with providing
therapeutic custom AFO’s for eligible patients. This includes office visits
and the AFO. In addition to providing a necessary service for your
patients, the bottom line is significant. The following is a typical scenario
for a patient:

VISIT #1 (Bill Medicare only):


MEDICARE MEDICARE
SERVICE CODE FEE ALLOWABLE* PAYMENT

Office visit 99213 60.00 52.00 42.00


Sub total: 60.00 52.00 42.00

VISIT #2 (Bill your DMERC only):


MEDICARE MEDICARE
SERVICE CODE FEE ALLOWABLE* PAYMENT

Dispense/fit custom (hinged) AFO L1970 800.00 589.00 471.00


Sub total: 800.00 589.00 471.00

VISIT #1 total fees: 52.00


VISIT #2 total fees: 589.00
Medicare allowable* total fees: 641.00
Costs** (excluding labor): 272.00
Profit: $369.00

Patients per Year 50 100 150 200


Patients Patients Patients Patients
Practice Revenue $32,050 $64,100 $96,150 $128,200

Practice Net Profit $18,450 $36,900 $55,350 $73,800

*Medicare 2000 allowable fee schedule. Fees may vary according to DMERC region
(see Appendix H).

**Costs include AFO and STS casting socks. These “lab” fees may vary according to
type of AFO prescribed and lab used.

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PATIENT RESPONSIBILITY FOR PAYMENT

Medicare will pay for 80% of the amount allowed either directly to the
patient or by reimbursement. The patient is responsible for a minimum of
20% of the total payment amount and possibly more if the dispenser does
not accept Medicare assignment and if the dispenser’s usual fee is higher
than the payment amount. The maximum Medicare reimbursement may
vary somewhat depending on where you practice but typical
reimbursement fees are as noted on the previous page.

WHAT PATIENTS QUALIFY FOR AFO’S?

Medicare and most other insurance carriers provide coverage for custom
fitted ankle-foot orthoses (AFO’s) for the following conditions when
indicated:

 Moderate to severe ankle arthropathy (osteoarthritis, Charcot joint, etc.)


 Tibialis posterior dysfunction
 Chronic lateral ankle instability
 Moderate to severe chronic/recurrent ankle sprains
 Drop foot conditions

DEFINITIONS:

An orthosis (brace) is a rigid or semi-rigid device, which is 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. An orthosis
can be either prefabricated or custom fabricated.

A prefabricated orthosis is one that is manufactured in quantity without a


specific patient in mind. A prefabricated orthosis may be trimmed, bent,
molded (with or without heat), or otherwise modified for use by a specific
patient (i.e., “custom fitted”). An orthosis that is assembled from
prefabricated components is considered prefabricated. Any orthosis that
does not meet the definition of a custom fabricated orthosis is considered
prefabricated.
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A custom fabricated orthosis is one which is individually made for a
specific patient starting with basic materials including, but not limited to,
plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves
substantial work such as cutting bending, molding, sewing, etc. It may
involve the incorporation of some prefabricated components. It involves
more than trimming, bending, or making other modifications to a
substantially prefabricated item. A molded-to-patient-model orthosis is
a particular type of custom fabricated orthosis in which an impression of
the specific body part is made by means of impression casting material
and this impression is then used to make a positive model (of plaster or
other material) of the body part. The orthosis is then molded on this
positive model.

Ankle-foot orthoses extend above the ankle and are fastened around the
lower leg above the ankle. These features distinguish them from foot
orthotics, which are shoe inserts that do not extend above the ankle.

COVERAGE AND PAYMENT RULES:

For any item to be covered by Medicare, it must:

 Fit into a defined Medicare category, e.g. “Braces” (Orthotics)

 Be reasonable and necessary for the diagnosis or treatment of illness or


injury or to improve the functioning of a malformed body member,
and

 Meet all other applicable Medicare statutory and regulatory


requirements.

For AFO’s used in ambulatory patients “reasonable and necessary” is


defined by the following coverage and payment rules:

For an item to be considered for coverage under the “Brace” benefit


category, it must be a rigid or semi-rigid device which is 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.

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Ankle–foot orthoses (AFO) described by codes L1900--L1990 and L2101--
L2116 are covered for ambulatory patients with weakness or deformity of
the foot and ankle, which require stabilization for medical reasons, and have
the potential to benefit functionally.

If the basic coverage criteria for an AFO are not met, the orthosis will be
denied as not medically necessary.

The purpose of a brace is to support a weak or deformed body member or


to restrict or eliminate motion in a diseased or injured part of the body.
When an AFO for an ambulatory patient and any related addition is used
solely for the treatment of edema and/or for the prevention or treatment of
a foot pressure ulcer, it will be denied as non-covered.

AFO's that are molded-to-patient-model are covered for ambulatory


patients when the basic coverage criteria listed above are met and one of
the following criteria are met:

 The patient could not be fit with a prefabricated AFO, or

 The condition necessitating the orthosis is expected to be


permanent or of longstanding duration (more than 6 months), or

 There is need to control the ankle or foot in more than one plane, or

 The patient has a documented neurological, circulatory, or


orthopedic condition that requires custom fabrication over a model
to prevent tissue injury, or

 The patient has a healing fracture, which lacks normal anatomical


integrity or anthropometric proportions.

If the specific criteria for a molded-to-patient-model orthosis are not met,


but the criteria for a prefabricated, “custom fitted” (i.e., “modified” prefab
orthosis) are met, payment will be based on the allowance for the least
costly medically appropriate alternative.

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MISCELLANEOUS BILLING REQUIREMENTS

Evaluation of the patient, taking measurements and/or casting, and fitting


of the orthosis are included in the allowance for the orthosis. There is no
separate payment from DMERC for these services. However, as a
podiatrist, you can bill your Medicare carrier for the office visit whereby
the determination of need for the AFO is established and documented.
Typically this visit is billed at the time you cast the patient for the custom
molded device (this will be discussed in more detail in Appendix D).

Repairs to a covered orthosis due to wear or to accidental damage are


covered when they are necessary to make the orthosis functional. The
reason for the repair must be documented in your record. If the expense
for the repairs exceeds the estimated expense of providing another entire
orthosis, no payment will be made for the amount in excess.

Replacement of a complete orthosis or component of an orthosis due to


loss, significant change in the patient’s condition, irreparable wear, or
irreparable accidental damage is covered if the device is still medically
necessary. The reason for the replacement must be documented in your
records.

CODING GUIDELINES

Codes L1900-L1990 and are used for an ankle-foot orthosis which is worn
when a patient is ambulatory. Typically, the podiatrist must decide
whether to prescribe a hinged (articulated) or solid (non-articulated)
device. The type of device prescribed must be appropriate for the
condition being treated. For example, you would not prescribe a hinged
AFO for a drop-foot deformity (unless, of course, you included a spring-
loaded modification to the AFO to keep the foot dorsiflexed).

Code L4205 is used for the labor component of repair of a previously


provided orthosis except for any labor involved in the replacement of an
orthotic component that has a specific L code. It may only be billed for
the actual time involved in the repair of an orthosis. It must not be used
for any labor involved in the evaluation, fabrication, or fitting of a new or
full replacement orthosis. As mentioned above, labor involved in the
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replacement of an orthotic component that has a specific L code is not
separately billable.

The right (RT) and left (LT) modifiers must be used with orthosis base
codes, additions, and replacement parts. When the same code for bilateral
items (left and right) is billed on the same date of service, bill both items
on the same claim line using the LTRT modifiers and 2 units of service.

Any questions concerning the coding of specific products must be directed


to your DMERC.

DOCUMENTATION

As the treating physician and supplier, you must document the need for
the orthosis as part of the patient’s medical record. In addition, a copy of
the order form should be kept on file and also incorporated into the
medical record. The order form must list the unique features of the base
code that is billed plus every addition that will be billed on a separate
claim line. The medical record must contain information that supports the
medical necessity of the custom molded AFO and all additions that are
ordered. An order is not necessary for the repair of an orthosis.

As mentioned previously, for custom fabricated orthoses, there must be


documentation in your records to support the medical necessity of that
type device rather than a prefabricated orthosis (see page 6). This
information does not have to be routinely sent in with the claim, but must
be available to your DMERC on request.

WHO IS THE PRESCRIBING PHYSICIAN?

A podiatrist (or other qualified physician such as an orthopedic foot


surgeon) knowledgeable in ankle and foot biomechanics can prescribe for
AFO’s. (See Appendix C for sample prescription form.)

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WHO CAN FURNISH THE AFO?

Once the patient has the AFO prescription, the device can be furnished by
the podiatrist and fitted to the patient. Therefore, the podiatrist can be both
the prescribing physician and the supplier. As a supplier, you need to
have a National Supplier Number in addition to your Medicare provider
number (this will be explained later).

HOW DO I START THIS PROGRAM FOR MY PRACTICE?

To determine how to proceed, review the “flow chart” on the following


page to determine what steps you need to take to participate in the
Medicare program for billing for AFO’s. Refer to the appropriate
appendix for more information. If you still have questions, call STS at
800-787-9097 for further information.

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APPENDIX A

APPLYING FOR MEDICARE PROVIDER NUMBER

Most podiatrists reading this manual probably already have their


Medicare provider number and participate in the Medicare program.
However, for new practitioners, the following may be helpful.

To participate in the Medicare program you must have a Medicare ID


provider number. Medicare hires “contractors” (carriers) to process
enrollment applications and enroll the practitioner. For practical
purposes each state is assigned a carrier, a fiscal intermediary, a state
agency and a regional office (the country is divided into 10 regions).
You must contact the Medicare carrier assigned to your state to obtain
information about your specialty. This is very easy to do on the
Internet. Go to the following website to select the State in which you
practice:

www.hcfa.gov/medicare/enrollment/contacts/

After selecting the state, you will receive information regarding your
region number, carrier, fiscal intermediary and state agency.

The carrier will provide you with information concerning the


application(s) you need to complete and other supporting documents
that need to be attached to obtain a Medicare billing number. Once
you complete the application and have obtained the necessary
supporting documentation (license, certifications, etc.) you need to
submit the information to the carrier. The carrier should process your
application within 45 days, absent extenuating circumstances. Keep
in mind that Medicare does make provision for the “waiting” provider
to retroactively bill Medicare claims once a provider number is
received.
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When an applicant provider fills out the HCFA 855 (provider
application), in the area of the form where it asks for the date that the
practice began, make sure that the date entered is (or just prior to) the
first date the applicant examined and treated Medicare patients. Once
the provider is credentialed by the carrier—confirmed by letter—all
claims “held” by the provider from the time the first Medicare patient
was seen (start date) can then be submitted for belated payment.
Those claims will then be processed in the carrier’s customary
fashion.

If you have already submitted an application, and have a problem


with the carrier, you should contact your Health Care Financing
Administration’s regional office. The regional office has the
responsibility for monitoring the carrier’s performance and will be
glad to assist you.

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APPENDIX B

BECOMING A “DMEPOS” SUPPLIER

Once you have enrolled in the Medicare program and have received a
Medicare provider number you can then apply for a durable medical
equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier
number. You need this number to bill for custom molded AFO’s.
This application process is handled by another entity called the
National Supplier Clearinghouse.

The application to become a DMEPOS supplier is 11 pages long (we


can fax you a copy of this application at your request). The good
news is that it is pretty straight forward and can be downloaded from
the National Supplier Clearinghouse website where the data fields can
be filled in through your personal computer. The form, however, will
still need to be printed upon completion and the “hard copy” mailed
to the National Supplier Clearinghouse.

To download the application, go to the following website:

www.palmettogmb.com

Mail the completed application to:

National Supplier Clearinghouse


P.O. Box 100142
Columbia, SC 29202-3142
Phone: 866-238-9652

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APPENDIX C

CUSTOM MOLDED AFO PRESCRIPTION FORM

The prescribing physician can be a podiatrist or an M.D. Once the


patient has obtained the signed AFO prescription, he/she can see a
“supplier” (podiatrist, orthotist or prosthetist) to have the prescription
filled. The supplier will then submit the appropriate Medicare claim
form(s) for payment (See Appendix D and E). As discussed
previously, custom molded AFO’s are covered only when the patient
has a foot deformity or condition that cannot be accommodated by an
“off-the-shelf “ device. Therefore, when prescribing for a “molded to
a patient model” AFO, a statement on the prescription and in the
chart, should be added indicating the foot/ankle condition is not
amenable to an off-the-shelf orthosis. Any one of the following
conditions qualify for providing an ambulatory patient with a custom
molded device and provides justification as to why a prefabricated
device cannot be used:

 The condition necessitating the orthosis is expected to be


permanent or of longstanding duration (more than 6 months).

 There is need to control the ankle or foot in more than one


plane.

 The patient could not be fit with a prefabricated AFO.

 The patient has a documented neurological, circulatory, or


orthopedic condition that requires custom fabrication over a
model to prevent tissue injury.

 The patient has a healing fracture that lacks normal anatomical


integrity or anthropometric proportions.

As mentioned in the preceding section, if the specific criteria for a

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molded-to-patient-model orthosis are not met, but the criteria for a
prefabricated, “custom fitted” orthosis are met, payment will be based
on the allowance for the least costly medically appropriate alternative
i.e., the prefabricated device.

A suggested prescription form for a custom AFO can be found on the


following page. This can be attached to the order form provided by
the company/lab that does the actual AFO fabrication. A list of
custom AFO fabrication labs can be found in Appendix F. Needless
to say, a copy of all prescriptions should be part of the patient’s chart.

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Prescription Form for Ankle Foot Orthosis

Patient Name: ________________________HIC#__________________________

Address:
_____________________________________________________________________
________________________________________________________

Diagnosis: _________________________________________________________

Change to be effected:
___________________________________________________________

Additional relevant information, such as type of orthosis, area of concern or allergies


to specific materials:
_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________

Prescribing Physician Information:

Signature: _____________________________Date: ________________________

Name: ________________________________DEA#_______________________

Medicare UPIN#________________ Medicaid provider #____________________

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APPENDIX D

BILLING MEDICARE FOR OFFICE VISITS

The podiatrist can bill his/her Medicare carrier for the visit associated
with the determination of need for a custom ankle foot orthosis. With
Medicare, no pre-certification is required. However, some private
carriers or HMO’s may require some type of pre-authorization before
payment is allowed. Thus, you should check with the patient’s
private or HMO carrier to determine if pre-authorization is required.

Typically, the billing for these initial services is submitted after the
cast is taken. The proper claim form for billing your Medicare carrier
is the HCFA (1500) form. The second billing is submitted after the
AFO is fitted and dispensed. However, as will be discussed in
Appendix E, billing for the actual device itself is submitted to your
DMERC. If, at the time of dispensing the AFO, the patient presents
with an unrelated problem or condition such as cellulitis, ulcer
formation, ingrown nail, etc., you can bill for this “dispensing” office
visit using the appropriate E/M code with modifier “--24”. Make sure
the new condition or problem is well documented.

The next page represents a typical claim form for the “first” visit
whereby the need for a custom AFO is established (and presumably
documented in the chart). The following are tips and points to keep
in mind when filling out this form:

 Box 21: Make sure the diagnosis is appropriate for justification


of the AFO dispensed (see page 4).

 Box 24(B): Make sure the place of service is “11” (office).

 Box 33: Make sure the PIN# is your Medicare Provider #.

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APPENDIX E

BILLING YOUR DMERC FOR CUSTOM AFO

The country is divided into 4 regions and each is served by a separate


and distinct DMERC. The state in which you permanently reside
determines which carrier should receive your claims. To determine
what carrier is assigned to manage your DMERC claims, see the
following list:

DURABLE MEDICAL EQUIPMENT CARRIERS


STATE REGION

ALABAMA Region C REGION "A" DMERC: HealthNow NY


ALASKA Region D P.O. Box 6800
ARIZONA Region D Wilkes-Barre, PA 18773-6800
ARKANSAS Region C (570) 735-9445
CALIFORNIA Region D www.medicare-link.com
COLORADO Region C
CONNECTICUT Region A
DELAWARE Region A
DISTRICT OF COLUMBIA Region B
FLORIDA Region C
GEORGIA Region C REGION "B" DMERC: AdminaStar Federal Inc.
GUAM (AMERICAN) Region D P.O. Box 7078
HAWAII Region D Indianapolis, IN 46207-7078
IDAHO Region D (877) 299-7900
ILLINOIS Region B www.astar-federal.com
INDIANA Region B
IOWA Region D
KANSA Region D
KENTUCKY Region C
LOUISIANA Region C
MAINE Region A REGION "C" DMERC: Palmetto GBA
MARIANNA ISLANDS Region D P.O. Box 100141
MARYLAND Region B Columbia, SC 29202-3141
MASSACHUSETTS Region A (866) 238-9650
MICHIGAN Region B www.palmettogmb.com
MINNESOTA Region B
MISSISSIPPI Region C
MISSOURI Region D
MONTANA Region D
NEBRASKA Region D

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NEVADA Region D REGION "D" DMERC: General Life Insurance Company
NEW HAMPSHIRE Region A (CIGNA MEDICARE)
NEW JERSEY Region A P.O. Box 690
NEW MEXICO Region C Nashville, TN 37202
NEW YORK Region A (877) 320-0390
NORTH CAROLINA Region C www.cignamedicare.com
NORTH DAKOTA Region D
OHIO Region B
OKLAHOMA Region C
OREGON Region D
PENNSYLVANIA Region A
PUERTO RICO Region C
RHODE ISLAND Region A
SAMOA Region D
SOUTH CAROLINA Region C
SOUTH DAKOTA Region D
TENNESSEE Region C
TEXAS Region C
UTAH Region D
VERMONT Region A
VIRGIN ISLANDS Region C
VIRGINIA Region B
WASHINGTON Region D
WISCONSIN Region B
WYOMING Region D

The proper claim form for billing your durable medical equipment
regional carrier (DMERC) is the HCFA (1500) form. This form is
used for billing for the custom molded AFO.

As a general rule, it’s a good idea to make copies of all forms for your
records before sending them to your DMERC. Also, all forms
submitted to your DMERC need to be hand signed and not stamped
with your signature.

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The next page represents a typical claim form for the “second” or
dispensing visit. The following are tips and points to keep in mind
when filling out this form:

 Box 21: Make sure the diagnosis is appropriate for justification


of the AFO being dispensed (see page 4).

 Box 24(B): Make sure the place of service is “12” (home).

 Box 24(D): Make sure the AFO device is appropriate for the
diagnosis (see page 4).

 Box 24(D): Be sure to use the “LT” or “RT” modifier.

 Box 33: Make sure the PIN# is your DMERC Provider #.

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APPENDIX F

CUSTOM AFO FABRICATION LABS/COMPANIES

Allied OSI Labs* Orthoamerica Products, Inc.


6299 Guion Road 6333 North Orange Blossom Trail
Indianapolis, IN 46268-2530 Newport Beach, CA 92663
Tel: (888) 264-3338 Tel: (800) 446-6770
Fax: (317) 299-1367 Fax: (800) 638-9259
www.orthomerica.com

Arizona AFO / Custom Footwear** PAL Health Systems


1306 E. Main Street 1805 Riverway Drive
Mesa, AZ 85203 Pekin, IL 61554
Tel: (480) 461-1940 Tel: (800) 223-2957
Fax: (480) 926-0304 Fax: (309) 347-3618
www.customfootwear.com Www.palhealthsystems.com/

KLM Orthotics* ProLab Orthotics/USA*


27510 N. Avenue Mentry 379 Oyster Point Blvd, Suite #1
Valencia, CA 91355 So. San Francisco, CA 94080
Tel: (800) 556-3668 Tel: (800) 477-6522
Fax: (800) 556-3338 Fax: (650) 589-8050
www.klm-lab.com www.prolaborthotics.com

Johnson’s Orthopedic Designs* Seattle Orthopedic Group


1516 Commerce Street, Suite E 26296 Twelve Trees Lane NW
Corona, CA 92880 Building #1
Tel: (800) 523-6774 Poulsbo, WA 98370
Fax: (909) 278-2032 Tel: (800) 248-6463
www.oandp.com/products/Johnsons/ Fax: (800) 568-6463
www.soginc.com/

* “Richie Brace” fabrication facility.


** “Arizona Brace” fabrication facility

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APPENDIX G

DEVICE DESCRIPTION

CODE DEVICE

L1900 Ankle-foot orthosis (AFO), spring wire, dorsiflexion assist calf band
L1902 AFO, ankle gauntlet
L1904 AFO, molded ankle gauntlet, molded to patient model
L1906 AFO, multiligamentus ankle suport
L1910 AFO, posterior, single bar, clasp attachment to shoe counter
L1920 AFO, single upright with static or adjustable stop (Phelps or Perlstein type)
L1930 AFO, plastic
L1940 AFO, molded to patient model, plastic
L1945 AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction)
L1950 AFO, spiral, molded to patient model (IRM type), plastic
L1960 AFO, posterior solid ankle, molded to patient model, plastic
L1970 AFO, plastic molded to patient model, with ankle joint ("Richie Brace")*
L1980 AFO, single upright free plantar- and dorsiflexion, solid stirrup, calf band/cuff
(single bar "BK" orthosis)
L1990 AFO, double upright free plantar- and dorsiflexion, solid stirrup, calf band/cuff
(double bar "BK" orthosis)
L2220 Addition to lower extremity, limited ankle motion, each joint
L2210 Addition to lower extremity, dorsiflexion assist (plantarflextion resist), each joint
L2220 Addition to lower extremity, dorsiflexion and plantarflexion assist/resist, each joint

*The “Richie Brace” is a custom articulated supra-malleolar ankle-foot orthosis (AFO). It is a patented
device that incorporates a custom balanced functional foot orthosis articulated to a double-upright semi-rigid
ankle brace. Since its introduction to the podiatric and orthopedic marketplace in 1998, this device has been
prescribed successfully for a number of challenging foot and ankle pathologies, especially posterior tibial
tendon dysfunction.

The Richie Brace addresses the severe adult acquired flatfoot by providing a “UCBL” type of aggressive,
balanced, foot orthosis incorporating a 35mm. heel cup, high medial arch flange and a 6mm. medial heel
skive incorporated into the positive plaster cast correction. The limb uprights control transverse plane tibial
rotation, which can be the primary dominant deforming force in the adult acquired flatfoot.

The Richie Brace is billed and reimbursed under HCPCS “L1970”. A negative impression cast incorporating
the ankle malleoli is required. The HCPCS code is inclusive of casting (although, as mentioned previously,
casting supplies can be billed separately using the “A4590” code), the device itself and the dispensing of the
device. It is paid by Medicare, Workers’ Compensation, and non-Medicare payers as an AFO. As is the case
with other AFO’s, when billed to Medicare, it is billed through your regional DMERC contractor and,
therefore, a DMERC provider number is required. Keep in mind that, as is the case with all devices billed to
a third party payer, medical necessity must be clearly evident.

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APPENDIX H

FEE SCHEDULES

Each of the four DMERC’s is responsible for determining the fee schedule
under their jurisdiction. Each state within a given DMERC may have a different
allowable fee for an AFO. For example, at the time of this writing, for a custom
molded AFO with hinge (“Richie Brace”), the maximum allowable fee in
California is $554.85. For the same device, the maximum allowable fee in the
state of Oregon is $531.11. Both California and Oregon are under the Region
“D” DMERC jurisdiction.

To determine what your maximum allowable fee is for any given device,
proceed as follows:

 Using the “L” Code definitions in Appendix G, determine which


code is most appropriate for the device you are supplying.

 Go to the following website:

www.hcfa.gov/stats/pufiles.htm

 Scroll down to “Payment Rates—Non Institutional Provider”

 Click on the DME01_A.exe file to open a spreadsheet entitled:

Durable Medical Equipment,


Prosthetics, Orthotics, and Supplies
(DMEPOS)
2001 Fee Schedule
12/19/2000
(This date will change depending on most recent update)

 The AFO “L” codes begin on row 1480. Scroll down to this area of
the spreadsheet to the L code you are going to use. Then move your
cursor to the your state column (8-58) to determine your DMERC
maximum allowable fee.
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Fee schedule updates:

The DMEPOS fee schedule is updated on a quarterly basis, with the


January 1 implementation date being the primary update. In addition to
the January file, updated public use files (PUFs) will be available in early
April, July, and October. Carriers will implement these updates by mid-
month. These PUFs will be complete replacement files for the DMEPOS
fee schedule, not only the quarterly changes.

Because of the DMEPOS fee schedule quarterly update process, the


executable file you receive will be named for the quarterly release
corresponding to that file. The following conventions are used to identify
each DMEPOS fee schedule PUF:

DME01__A.EXE January 2001 release


DME01__B.EXE Second Quarter 2001 release
DME01__C.EXE Third Quarter 2001 release
DME01__D.EXE Fourth Quarter 2001 release

28
DISCLAIMER

The opinions and facts contained herein are not the official position of any
organization. Coding and documentation rules are not simply black and
white, and may be subject to other interpretations. The various Medicare
and DMERC carriers differ in their medical policies for coding and
documentation of the identical patient encounter. The practitioner is
urged to contact his or her local carrier to discuss any statements made in
this manual. In cases where variability exists, the practitioner must
conform to the rules promulgated by the local carrier.

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