DME Treatment Protocol and Compliance

Report
Diagnosis Specific DME
Treatment Protocols
and Charting Compliance
Oklahoma Podiatric Medical Association
May 11, 2012
Hal Ornstein, DPM, FASPS
Chairman, American Academy of
Podiatric Practice Management
22 years in Private Practice
Howell, New Jersey
Reasons To Follow
Treatment Protocols
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Easy to follow
Consistent with standards of care
Medico-legal security
Ease of inventorying
Improved outcomes
Improved patient satisfaction
Patient convenience
Note
change of
L Code...
explained
on next
slide
***Fee Ceiling: as published for 2010
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."
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.
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.
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.
1906 vs. 1902
L1906
ANKLE FOOT ORTHOSIS,
MULTILIGAMENTUS ANKLE
SUPPORT, PREFABRICATED,
INCLUDES FITTING AND
ADJUSTMENT
Darco Body Armor Sport ~ Sweed-O White/Black
Suggested Code: L1906
DMEPOS Fee Ceiling: $138.87
L1902
ANKLE FOOT ORTHOSIS,
ANKLE GAUNTLET,
PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
Ossur GameDay
Suggested Code: L1902
DMEPOS Fee Ceiling: $90.11
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
L1902
L1906
L4386
L4396
L4360
L1971
L4350
L1932
L1951
Non covered
AFO, Gauntlet style
AFO, Multiligamentous
AFO, Non-pneumatic walking
AFO, Plantarfascia night splint
AFO, Pneumatic below knee
AFO, With ankle joint
AFO, Ankle control orthotics
AFO, Dynamic
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 are
covered for use
of 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 coverage
for ulcers
Medical Justification for AFOs
State Functional Benefits
Covered 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 site
729.5 Pain in limb
719.07 Unspecified disorder of ankle
and foot
Ankle Sprain ~ Grade 1
Initial Visit
Ossur GameDay
Suggested Code: L1902
DMEPOS Fee Ceiling:
$92.19
Ankle Sprain ~ Grade 2 & 3
Possible Diagnosis Codes:
729.5
719.07
845.02
845.01
824.2
824.6
Ankle pain and support
Effusion of joint, ankle, foot
Sprain and strain of ankle and foot, calcaneofibular
Sprain and strain of ankle and foot, deltoid ligament
Ankle fracture, lateral malleolus only
Ankle fracture, trimalleolar
Ankle Sprain ~ Grades 2 & 3
Initial Visit
SafeStep DME
Adjustable Low
Top Walker
Ossur
Equalizer
Premium Air
Walker
SafeStep Adjustable
Air Walker
Ossur Rebound Air
Walker
Pneumatic Walker
All SafeStep DME
Available with
custom logo
Suggested Code: L4360
DMEPOS Fee Ceiling: $319.75
Ankle Sprain ~ Grade 2 & 3
Follow up visit, 2 - 6 weeks
Delayed Healing
Healing Well
Ossur GameDay
Ossur Exoform
Suggested Code: L1902
DMEPOS Fee Ceiling:
$92.19
Suggested Code: L1902
DMEPOS Fee Ceiling:
$92.19
Ossur Rebound
Hinged Ankle
Brace
Suggested Code: L1971
DMEPOS Fee Ceiling: $517.14
Ankle Instability
Possible Diagnosis Codes:
845.02 Sprain and strain of ankle and
foot, calcaneofibular
845.00 Sprain and strain of ankle and
foot, unspecified
Ankle Instability:
Initial Visit
Moderate
Mild
Ossur GameDay
Ossur Exoform
Suggested Code: L1902
DMEPOS Fee Ceiling: $92.19
Suggested Code: L1902
DMEPOS Fee Ceiling:
$92.19
Ossur Rebound
Hinged Ankle
SuggestedBrace
Code: L1971
DMEPOS Fee Ceiling:
$517.14
Plantar Fasciitis
Possible Diagnosis Codes:
728.71 Plantar fascial fibromatosis
Plantar fasciitis:
Initial Visit
Aircast Airheel
Suggested Code: L2999
Patient Pays
PowerStep Insert
Suggested Code:
L2999
Patient Pays
Plantar fasciitis:
Subsequent Visit
SafeStep DME
Dorsal Night Splint
SafeStep DME
PosteriorNight Splint
Darco
Dorsal Night Splint
Night Splint ~ Posterior or Dorsal
Suggested Code: L4396
DMEPOS Fee Ceiling: $184.82
Plantar fasciitis: Subsequent Visit
Severe
SafeStep DME Low
Top Air Walker
Ossur Rebound Low
Walker
Pneumatic Walker
Suggested Code: L4360
DMEPOS Fee Ceiling:
$319.75
Posterior Tibialis Tendonitis
Possible Diagnosis Codes:
726.72 Tibialis tendonitis
905.8 Late effect of tendon injury, sprain, strain
Posterior Tibialis Tendonitis Mild
Initial Visit
PowerStep Insert
Aircast Airlift PTTD
Suggested Code: L2999
Patient Pays
Suggested Code: L4350
DMEPOS Fee Ceiling: $103.23
Posterior Tibialis Tendonitis
Moderate: Initial Visit
Darco Vario
Suggested Code: L1971
*can also include code L2275
DMEPOS Fee Ceiling: $517.14
Ossur Rebound
Hinged Ankle Brace
Suggested Code: L1971
DMEPOS Fee Ceiling: $517.14
Posterior Tibial Tendonitis
Severe, Initial Visit
Ossur Equalizer Premium
Air Walker
SafeStep DME Air Walker
Pneumatic Walker
Suggested Code: L4360
DMEPOS Fee Ceiling:
$319.75
Posterior Tibialis Tendon Rupture
Stage 3
Possible Diagnosis Codes:
727.68 Rupture, tendon of foot and ankle, non-traumatic
728.4 Laxity of ligament
734
Flat foot, acquired
Posterior Tibialis Tendon
Rupture, Stage 3: Initial Visit
SafeStep DME Air Walker
Ossur Rebound Air
Walker
Pneumatic Walker
Suggested Code: L4360
DMEPOS Fee Ceiling:
$319.75
Posterior Tibialis Strain
Rupture, Stage 3:
Subsequent Visit, if getting better
Less Severe
Aircast Airlift PTTD
Suggested Code: L4350
DMEPOS Fee Ceiling:
$103.23
More Severe
Darco Vario
Ossur
Rebound
Suggested Code: L1971
DMEPOS Fee Ceiling: $517.14
Posterior Tibialis Tendon
Rupture ~ Stage 3:
Subsequent Visit, if getting worse
Arizona Standard AFO
AZ Split Upright or Richie AFO
Suggested Codes: L1940, L2330, L2820
Suggested Codes: L1970, L2820
DMEPOS Fee Ceiling: $1099
DMEPOS Fee Ceiling: $901
Tarsal Tunnel Syndrome
Possible Diagnosis Codes:
355.5 Tarsal tunnel syndrome
719.47 Pain in joint, ankle, foot
Tarsal Tunnel Syndrome:
Initial Visit
Moderate
Mild
Ossur GameDay
Ossur Exoform
Suggested Code: L1902
DMEPOS Fee Ceiling: $92.19
Suggested Code: L1902
DMEPOS Fee Ceiling: $92.19
Ossur Rebound
Hinged Ankle
Brace
Suggested Code: L1971
DMEPOS Fee Ceiling: $517.14
Severe Tarsal Tunnel Syndrome
Initial Visit
SafeStep DME Low Top
Air Walker
All SafeStep
DME Available
with custom
logo
Ossur Rebound Low
Top Air Walker
Pneumatic Walkers
Suggested Code: L4360
DMEPOS Fee Ceiling:
$319.75
Severe Tarsal Tunnel Syndrome:
Subsequent Visit
Ossur GameDay
Suggested Code: L1902
DMEPOS Fee Ceiling: $92.19
Aircast Airlift PTTD
Suggested Code: L4350
DMEPOS Fee Ceiling:
$103.23
Peroneal Tendonitis
Possible Diagnosis Codes:
726.79 Enthesopathy of ankle and tarsus
Peroneal Tendonitis
Initial Visit
Mild to Moderate
Ossur Game Day
Suggested Code: L1902
DMEPOS Fee Ceiling:
$92.19
Peroneal Tendonitis ~ Severe
Initial Visit
SafeStep
Low Top Air Walker
Ossur Equalizer
Premium Air
Walker
Aircast SP Walker
Pneumatic Walkers
Suggested Code: L4360
DMEPOS Fee Ceiling:
$319.75
Ossur Rebound Air
Walker
Achilles Tendonitis
Achilles Tendon Rupture
Possible Diagnosis Codes:
845.09 Achilles tendon strain, rupture
726.71 Achilles tendonitis
Achilles Tendonitis ~ Achilles Tendon Tear
Initial Visit
SafeStep DME Air Walker
Ossur Rebound Air Walker
Pneumatic Walkers
Suggested Code: L4360
DMEPOS Fee Ceiling:
$319.75
Achillies Tendonitis with Plantar Flexion
Contracture of the Ankle (718.47)
Initial Visit
Ossur Formfit
Posterior Night Splint
SafeStep DME Dorsal
Night Splint
Ossur Airform
Dorsal Night Splint
Night Splint ~ Posterior or Dorsal
Suggested Code: L4396
DMEPOS Fee Ceiling: $184.82
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, unspecified
825.25 Fracture of the metatarsal bone
Metatarsal Fracture:
Initial visit
SafeStep DME
Non-Pnematic Low Top
Walker
Suggested Code: L4386
DMEPOS Fee Ceiling:
$174.36
Darco Med-Surg Walker
Suggested Code: L2999
DMEPOS Fee Ceiling: Patient pays
Metatarsal Fracture:
Follow up visit
PowerStep ProTech Prefabricated Orthotic
Suggested Code: L2999
DMEPOS Fee Ceiling: Patient pays
Flaccid Drop Foot
736.79
438.20
719.97
356.1
340
138
Possible Diagnosis Codes:
Acquired deformity of foot and ankle
Hemiplegia
Joint derangement, ankle and foot
Peroneal muscle atrophy, Charcot Marie Tooth disease
Multiple sclerosis
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.
When can a person get
another device?
Upon examination and documentation of
change in status. Medical justification is
established chart notes.
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.
866-712-7837
www.safestep.net
Thank you!

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