Professional Documents
Culture Documents
CUSTOM FABRICATED
ANKLE-FOOT ORTHOSES
Introduction:
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THE ECONOMICS OF PRESCRIBING CUSTOM AFO’S
*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.
Medicare and most other insurance carriers provide coverage for custom
fitted ankle-foot orthoses (AFO’s) for the following conditions when
indicated:
DEFINITIONS:
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.
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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.
There is need to control the ankle or foot in more than one plane, or
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MISCELLANEOUS BILLING REQUIREMENTS
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).
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.
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.
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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).
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APPENDIX A
www.hcfa.gov/medicare/enrollment/contacts/
After selecting the state, you will receive information regarding your
region number, carrier, fiscal intermediary and state agency.
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APPENDIX B
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.
www.palmettogmb.com
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APPENDIX C
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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.
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Prescription Form for Ankle Foot Orthosis
Address:
_____________________________________________________________________
________________________________________________________
Diagnosis: _________________________________________________________
Change to be effected:
___________________________________________________________
Name: ________________________________DEA#_______________________
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APPENDIX D
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:
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APPENDIX E
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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 24(D): Make sure the AFO device is appropriate for the
diagnosis (see page 4).
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APPENDIX F
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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:
www.hcfa.gov/stats/pufiles.htm
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:
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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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