AFO Designs You Should Use Josh White, DPM, Cped Founder, SafeStep Commonly Seen Biomechanical Disorders Ankle Sprain Gait Instability Posterior Tibial Tendon Rupture Achilles Tendonitis, Rupture Charcot, Active Flaccid Drop Foot Commonly used AFO Categories/DME HCPCS Codes L1906 L4387 L4397 L4398 L4361 L4350 L1951 AFO, Gauntlet style AFO, Multiligamentous AFO, Non-pneumatic walking AFO, Posterior night splint AFO, Dorsal night splint AFO, Pneumatic below knee AFO, Ankle control orthotics AFO, Spiral, plastic, other When to use these L Codes "Ankle-foot orthoses (AFO) described by codes L1900, -L1990, L2106- L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally". Medical Justification for AFOs Covered for ambulatory patients with weakness or deformity of the foot and ankle who require stabilization and have the potential to benefit functionally. Example: 1906 vs. 1902 L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT AFO must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semirigid support) on the limb or body part that it is being used to brace. Chart Notes establish Medical Justification for custom vs. non-custom SSDME Hinged Multiligamentous ~ L1906 $138.87 Ossur GameDay $90.11 1
Ankle Sprain ~ Grade 1 Ankle Sprain ~ Grade 1 S93.411 Sprain of ankle calcaneofibular ligament, right S93.412 Sprain of ankle calcaneofibularligament, left Ossur GameDay Ankle Sprain ~ Grade 2 & 3 Ankle Sprain ~ Grades 2 & 3 M25.571 Pain in ankle and joints of foot, right M25.572 Pain in ankle and joints of foot, left M24.871 Joint derangements of ankle, right M24.872 Joint derangements of ankle, left S93.441 Sprain of ankle, calcaneofibular, right S93.442 Sprain of ankle, calcaneofibular, left SafeStep DME Adjustable Low Top All SafeStep DME Available with custom logo Ossur Equalizer Premium Air SafeStep Adjustable Air Air Pneumatic L4361 $325.53 L4360 vs. L4361 L4360 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE L4361 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE- SHELF Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis Off the Shelf vs. Custom Fitted Off the Shelf (OTS) items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual. This fitting does not require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthoses to fit the item to the individual beneficiary. The term minimal self-adjustment is defined at 42 CFR 414.402 as an adjustment the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. 2
Off the Shelf vs. Custom Fitted Ankle Sprain ~ Grade 2 & 3 Follow up visit, 2-6 weeks Custom fitted orthotics are: Devices that are prefabricated. Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal selfadjustment. This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. Healing Well Ossur GameDay Ossur Exoform DMEPOS Fee Ceiling: Delayed Healing Hinged Ankle Brace L1906 DMEPOS Fee Ceiling: $139.98 Gait Instability: Gait Instability Presence of any of the conditions listed would benefit from stabilization and qualifies patient for custom AFO L1940 ankle foot orthosis, molded to patient, plastic Plantar Fasciitis L2820 addition to lower extremity orthosis, soft interface for molded plastic, below knee section L2330 addition to lower extremity orthosis, lacer molded to patient model, for custom fabricated oorthoses only M72.2 Plantar fascial fibromatosis 3
L4396 vs. L4397 Plantar fasciitis: Subsequent Visit L4396 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE L4397 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, OFF-THE-SHELF SafeStep DME Posterior Night Splint L4397 $186.30 Darco Dorsal Night Splint L4397 $186.30 Plantar fasciitis: Subsequent Visit, Severe Posterior Tibialis Tendonitis SafeStep DME Low Top Air Low Pneumatic L4361 $319.75 M76.821 Posterior tibial tendonitis, right M76.822 Posterior tibial tendonitis, left Posterior Tibialis Tendonitis Mild Posterior Tibialis Tendonitis Moderate: PowerStep Insert L2999 Patient Pays Aircast Airlift PTTD L4350 $103.23 Darco Vario L19o6 $139.98 Hinged Ankle Brace L1906 $139.98 4
Posterior Tibial Tendonitis Severe, Posterior Tibialis Tendon Rupture Stage 3 Ossur Equalizer Premium Air Pneumatic L4361 $319.75 SafeStep DME Air M21.41 Flat foot, acquired, right M21.42 Flat foot, acquired, left M66.871 Spontaneous rupture of tendons of ankle, foot, R M66.872 Spontaneous rupture of tendons of ankle, foot, L Posterior Tibialis Tendon Rupture, Stage 3: Posterior Tibialis Strain Rupture, Stage 3: Subsequent Visit, if getting better Less Severe More Severe SafeStep DME Air Pneumatic L4361 DMEPOS Fee Ceiling: $319.75 Ossur Rebound Air Aircast Airlift PTTD L4350 $103.23 Darco Vario Assigned Code: L1906 $139.98 L1906 DMEPOS Fee Ceiling: $139.98 Posterior Tibialis Tendon Rupture ~ Stage 3: Subsequent Visit, if getting worse Tarsal Tunnel Syndrome Arizona Standard AFO Assigned Codes: L1940, L2330, L2820 $1099 AZ Optima or Richie AFO Suggested Codes: L1970, L2820 $901 M79.671 Pain in joint, ankle, foot, right M79.672 Pain in joint, ankle, foot, left M65.871 Other synovitis, ankle, foot, right M65.872 Other synovitis, ankle, foot, left 5
Mild Tarsal Tunnel Syndrome: Moderate Severe Tarsal Tunnel Syndrome Ossur GameDay Ossur Exoform Hinged Ankle Brace Assigned Code: L1906 $139.98 All SafeStep DME Available with custom logo Pneumatic s L4361 $319.75 Severe Tarsal Tunnel Syndrome: Subsequent Visit Peroneal Tendonitis Aircast Airlift PTTD L4350 $103.23 M76.71 Peroneal tendinitis, right leg M76.72 Peroneal tendinitis, left leg M77.51 Other enthesopathy of right foot M77.52 Other enthesopathy of left foot Achilles Tendonitis Achilles Tendonitis with Plantar Flexion Contracture of the Ankle : S86.011 Strain of right Achilles tendon S86.012 Strain of left Achilles tendon M76.61 Achilles tendinitis, right leg M76.62 Achilles tendinitis, left leg Prerequisite to qualify for Medicare billing: Requires dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and, Reasonable expectation of the ability to correct the contracture; and, Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; and, Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons 6
Achilles Tendonitis ~ Achilles Tendon Tear Active Charcot SafeStep DME Air Pneumatic s L4361 $319.75 Air Acute neuropathic osteoarthropathy: Red Hot Swollen Charcot Restraint Orthotic (CROW) Features: Custom fit Transfers weight to anterior leg and knee Can accommodate plantar prominences Removable to permit wound care Flaccid Drop Foot Possible Diagnosis Codes: M21.371 Foot drop, acquired, M21.372 Foot drop, acquired, right left Codes: L4631 DMEPOS Fee Schedule Ceiling $1,715.14 Flaccid Drop Foot Peromax: Perosupport.tec L1951 $933.98 Suggested codes are based on publicly available information and are offered as a convenience to physicians. The authors make no claims, promises or guarantees as to the availability of reimbursement for any of the suggested products. It is within the sole discretion of physicians to determine the appropriate billing code for a product as well as whether the use of a product complies with medical necessity and other documentation requirements of the payor. Actual reimbursement may vary. Prices reflect 2012 HCPCS National Ceiling Fees. ***Not responsible for typographical errors. 7
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