Diagnosis Specific DME Treatment Protocols and Charting Compliance Oklahoma Podiatric Medical Association May 11, 2012 Hal Ornstein, DPM, FASPS Chairman,

Diagnosis Specific DME Treatment Protocols

and Charting Compliance

Oklahoma Podiatric Medical AssociationMay 11, 2012

Hal Ornstein, DPM, FASPSChairman, American Academy ofPodiatric Practice Management

22 years in Private PracticeHowell, New Jersey

Reasons To Follow Treatment Protocols

Easy to follow Consistent with standards of care Medico-legal security Ease of inventorying Improved outcomes Improved patient satisfaction Patient convenience

***Fee Ceiling: as published for 2010

Note change of L Code...explained on next

slide

Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 (ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT) are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification Matrix of the DME Coding System (DMECS). Products which have not received coding verification review from the PDAC must be billed with code A9270. Please refer to the advisory article titled Coding Guidelines for Ankle Foot Orthoses.

Recently, Medicare announced that the design of an L1906 device must "include a rigid

stirrup and foot plate which provides functional tracking of the ankle with hind-foot

and mid-foot stability during ambulation."

In summary, some items currently filed as L1906 will need to be reclassified as

L1902. All items that meet new definition of L1906 will need a

verification letter starting April 1, 2012.

Products that are currently listed on DMECS with L1906 will be end dated effective March 31, 2012 and changed to A9270 until a coding verification review has been completed by the PDAC.Thus, it is mandatory that manufacturers submit to PDAC devices for L1906 verification in order for them to qualify for reimbursement.There are some multiligamentous type devices that have been recommended to be billed using L1906 code such as the Ossur Exoform and the GameDay that do not have a foot plate. As such, they would need to be billed as A9270. They might more appropriately meet the description of L1902.

1906 vs. 1902L1906

ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED,

INCLUDES FITTING AND ADJUSTMENT

L1902ANKLE FOOT ORTHOSIS,

ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

Ossur GameDay Suggested Code: L1902

DMEPOS Fee Ceiling: $90.11

Darco Body Armor Sport ~ Sweed-O White/Black

Suggested Code: L1906DMEPOS Fee Ceiling: $138.87

Dear Ms. Williams:The Pricing, Data Analysis, and Coding (PDAC) Contractor provides Healthcare Common Procedural Coding System (HCPCS) assistance to manufacturers to ensure proper coding of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. The PDAC has reviewed the above listed products. It is our determination that the Medicare HCPCS code to use when billing the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) is:L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT,PREFABRICATED, INCLUDE'S FITTING AND ADJUSTMENT

Commonly used AFO Categories/DME HCPCS Codes

L2999 Non coveredL1902 AFO, Gauntlet styleL1906 AFO, MultiligamentousL4386 AFO, Non-pneumatic walkingL4396 AFO, Plantarfascia night splintL4360 AFO, Pneumatic below kneeL1971 AFO, With ankle jointL4350 AFO, Ankle control orthotics L1932 AFO, DynamicL1951 AFO, Spiral, plastic, other

When to use these L Codes…(basic coverage criteria)

"Ankle-foot orthoses (AFO) described by codes L1900, L1902-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".

Which diagnoses arecovered for useof non-custom

DME items (AFO's)?

There is no diagnoses list. Devices must meet "medical

justification".

* exceptions are specific criteria for night splint (L4396) and

no walking boot coveragefor ulcers

Medical Justification for AFOs

State Functional BenefitsCovered for ambulatory patients with weakness or deformity of the foot and ankle who require stabilization and have the potential to benefit functionally.

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 semi-rigid support) on the limb or body part that it is being used to brace.

Chart Notes establish “Medical Justification”

Justification for custom vs. non-custom

Ankle Sprain ~ Grade 1

Possible Diagnosis Codes:845.02 Sprain and strain of ankle and foot, calcaneofibular 845.00 Sprain and strain of ankle and foot, unspecified site729.5 Pain in limb719.07 Unspecified disorder of ankle and foot

Ankle Sprain ~ Grade 1Initial Visit

Ossur GameDay Suggested Code:

L1902DMEPOS Fee Ceiling:

$92.19

Ankle Sprain ~ Grade 2 & 3

Possible Diagnosis Codes:729.5 Ankle pain and support719.07 Effusion of joint, ankle, foot845.02 Sprain and strain of ankle and foot, calcaneofibular845.01 Sprain and strain of ankle and foot, deltoid ligament824.2 Ankle fracture, lateral malleolus only824.6 Ankle fracture, trimalleolar

Ankle Sprain ~ Grades 2 & 3

Initial Visit

Pneumatic WalkerSuggested Code: L4360


SafeStep Adjustable Air

Walker

Ossur Rebound Air Walker

Ossur Equalizer

Premium Air Walker

SafeStep DME

Adjustable Low Top Walker

All SafeStep DME Available with custom

logo

Ankle Sprain ~ Grade 2 & 3 Follow up visit, 2 - 6 weeks

Suggested Code: L1971DMEPOS Fee Ceiling:

$517.14

Delayed Healing

Healing Well

Ossur ReboundHinged Ankle

Brace

Ossur GameDay Suggested Code:


$92.19

Ossur Exoform Suggested Code:


$92.19

Ankle Instability

Possible Diagnosis Codes:845.02 Sprain and strain of ankle and foot, calcaneofibular845.00 Sprain and strain of ankle and foot, unspecified

Ankle Instability: Initial Visit

Mild Moderate


$517.14


Brace

Ossur GameDay Suggested Code: L1902


Ossur Exoform Suggested Code:


$92.19

Plantar Fasciitis

Possible Diagnosis Codes:728.71 Plantar fascial fibromatosis

Plantar fasciitis: Initial Visit

Aircast AirheelSuggested Code:

L2999Patient Pays

PowerStep InsertSuggested Code:

L2999Patient Pays

Plantar fasciitis: Subsequent Visit

Night Splint ~ Posterior or Dorsal


SafeStep DME Dorsal Night Splint

Darco Dorsal Night Splint

SafeStep DME PosteriorNight Splint

Plantar fasciitis: Subsequent Visit



Severe

Ossur Rebound Low Walker

SafeStep DME Low Top Air Walker

Posterior Tibialis Tendonitis

Possible Diagnosis Codes:726.72 Tibialis tendonitis905.8 Late effect of tendon injury, sprain, strain

Posterior Tibialis Tendonitis Mild Initial Visit

Aircast Airlift PTTDSuggested Code: L4350


PowerStep Insert

Suggested Code: L2999

Patient Pays

Posterior Tibialis Tendonitis Moderate: Initial Visit


$517.14


Brace

Darco VarioSuggested Code: L1971

*can also include code L2275


Posterior Tibial Tendonitis Severe, Initial Visit



SafeStep DME Air Walker

Ossur Equalizer Premium Air Walker

Posterior Tibialis Tendon RuptureStage 3

Possible Diagnosis Codes:727.68 Rupture, tendon of foot and ankle, non-traumatic728.4 Laxity of ligament734 Flat foot, acquired

Posterior Tibialis Tendon Rupture, Stage 3: Initial

Visit

Pneumatic Walker


$319.75

Ossur Rebound Air Walker

SafeStep DME Air Walker

Posterior Tibialis Strain Rupture, Stage 3:

Subsequent Visit, if getting better

Aircast Airlift PTTDSuggested Code:


$103.23

Less Severe

Darco Vario

More Severe

Ossur Rebound


$517.14

Posterior Tibialis TendonRupture ~ Stage 3:

Subsequent Visit, if getting worse

Arizona Standard AFOSuggested Codes: L1940, L2330,

L2820DMEPOS Fee Ceiling: $1099

AZ Split Upright or Richie AFOSuggested Codes: L1970,

L2820DMEPOS Fee Ceiling: $901

Tarsal Tunnel Syndrome

Possible Diagnosis Codes:355.5 Tarsal tunnel syndrome719.47 Pain in joint, ankle, foot

Tarsal Tunnel Syndrome: Initial Visit

Mild Moderate


$517.14

Ossur GameDay


$92.19


Brace

Ossur Exoform


$92.19

Severe Tarsal Tunnel Syndrome Initial Visit

Pneumatic WalkersSuggested Code: L4360


Ossur Rebound Low Top Air

Walker

SafeStep DME Low Top Air Walker

All SafeStep DME

Available with custom logo

Severe Tarsal Tunnel Syndrome:

Subsequent Visit

Ossur GameDay Aircast Airlift PTTDSuggested Code:

L4350DMEPOS Fee

Ceiling: $103.23


$92.19

Peroneal Tendonitis

Possible Diagnosis Codes:726.79 Enthesopathy of ankle and tarsus

Peroneal Tendonitis Initial VisitMild to Moderate

Ossur Game Day Suggested Code:


$92.19

Peroneal Tendonitis ~ SevereInitial Visit



Aircast SP Walker Ossur Rebound Air Walker

SafeStepLow Top Air Walker

Ossur Equalizer Premium Air

Walker

Achilles Tendonitis Achilles Tendon

Rupture

Possible Diagnosis Codes:845.09 Achilles tendon strain, rupture726.71 Achilles tendonitis

Achilles Tendonitis ~ Achilles Tendon Tear Initial Visit



Ossur Rebound Air WalkerSafeStep DME Air Walker

Achillies Tendonitis with Plantar Flexion Contracture of the Ankle

(718.47)Initial Visit

Night Splint ~ Posterior or Dorsal


Ossur Formfit Posterior Night Splint

Ossur AirformDorsal Night Splint

SafeStep DME Dorsal Night Splint

Achillies Tendonitis with Plantar Flexion Contracture of the Ankle

(718.47): 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

Metatarsal Fracture

Possible Diagnosis Codes:733.94 Stress fracture, unspecified825.25 Fracture of the metatarsal bone

Metatarsal Fracture: Initial visit

SafeStep DME Non-Pnematic Low Top

WalkerSuggested Code: L4386


Darco Med-Surg WalkerSuggested Code: L2999

DMEPOS Fee Ceiling: Patient pays

Metatarsal Fracture: Follow up visit

PowerStep ProTech Prefabricated Orthotic

Suggested Code: L2999DMEPOS Fee Ceiling: Patient pays

Flaccid Drop Foot

Possible Diagnosis Codes:736.79 Acquired deformity of foot and ankle438.20 Hemiplegia719.97 Joint derangement, ankle and foot356.1 Peroneal muscle atrophy, Charcot Marie Tooth disease340 Multiple sclerosis138 Poliomyelitis, late effects

Flaccid Drop Foot : Initial Visit

Euro International Peromax

Suggested Code: L1951

DMEPOS Fee Ceiling: $926

Chart Documentation

Chart Documentation

Chart Documentation

Chart Documentation

Frequently asked questions and answers

What if patient doesn't come in to pick up custom device?

After several attempts made to contact person and to no avail... the COST of the custom device can be billed to Medicare/Insurance. Send original invoice and explanation of no show for custom device pickup.

What if person dies?

As in the previous situation; the COST of the custom device can be billed to Medicare/Insurance. Send original invoice and explanation of death of patient.* Payment may reflect full ceiling fee, in that case, you are not obligated to refund Medicare. Keep full payment.

Upon examination and documentation of change in status. Medical justification is established chart notes.

When can a person get another device?

Disclaimer:

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.

Thank you!

866-712-7837 www.safestep.net

Documents

Diagnosis Specific DME Treatment Protocols and Charting Compliance Oklahoma Podiatric Medical Association May 11, 2012 Hal Ornstein, DPM, FASPS Chairman,