Presentation on theme: "Diagnosis Specific DME"— Presentation transcript:
1 Diagnosis Specific DME Treatment Protocolsand Charting ComplianceOklahoma Podiatric Medical AssociationMay 11, 2012Hal Ornstein, DPM, FASPSChairman, American Academy ofPodiatric Practice Management22 years in Private PracticeHowell, New Jersey
2 Reasons To Follow Treatment Protocols Easy to followConsistent with standards of careMedico-legal securityEase of inventoryingImproved outcomesImproved patient satisfactionPatient convenience
4 explained on next slide Note change ofL Code...explained on next slide***Fee Ceiling: as published for 2010
5 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.
6 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 A They might more appropriately meet the description of L1902.In summary, some items currently filed as L1906 will need to be reclassified as L All items that meet new definition of L1906 will need a verification letter starting April 1, 2012.
7 Darco Body Armor Sport ~ Sweed-O White/Black 1906 vs. 1902L1906ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL1902ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTDarco Body Armor Sport ~ Sweed-O White/BlackSuggested Code: L1906DMEPOS Fee Ceiling: $138.87Ossur GameDaySuggested Code: L1902DMEPOS Fee Ceiling: $90.11
8 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:L1906ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT,PREFABRICATED, INCLUDE'S FITTING AND ADJUSTMENT
9 Commonly used AFO Categories/DME HCPCS Codes L Non coveredL AFO, Gauntlet styleL AFO, MultiligamentousL AFO, Non-pneumatic walkingL AFO, Plantarfascia night splintL AFO, Pneumatic below kneeL AFO, With ankle jointL AFO, Ankle control orthoticsL AFO, DynamicL AFO, Spiral, plastic, other
10 (basic coverage criteria) 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".
11 Which diagnoses arecovered for useof non-customDME items (AFO's)?
12 There is no diagnoses list. Devices must meet "medical justification". * exceptions are specific criteria fornight splint (L4396) andno walking boot coveragefor ulcers
13 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.
14 Chart Notes establish “Medical Justification” Justification for custom vs. non-custom
15 Possible Diagnosis Codes: Ankle Sprain ~ Grade 1Possible Diagnosis Codes:Sprain and strain of ankleand foot, calcaneofibularSprain and strain of ankleand foot, unspecified sitePain in limbUnspecified disorder of ankleand foot
17 Possible Diagnosis Codes: Ankle Sprain ~ Grade 2 & 3Possible Diagnosis Codes:Ankle pain and supportEffusion of joint, ankle, footSprain and strain of ankle and foot, calcaneofibularSprain and strain of ankle and foot, deltoid ligamentAnkle fracture, lateral malleolus onlyAnkle fracture, trimalleolar
18 Ankle Sprain ~ Grades 2 & 3 Initial Visit SafeStep DME Adjustable Low Top WalkerOssur Equalizer Premium Air WalkerSafeStep Adjustable Air WalkerOssur Rebound Air WalkerPneumatic WalkerSuggested Code: L4360DMEPOS Fee Ceiling: $319.75All SafeStep DME Available with custom logo
36 Severe Tarsal Tunnel Syndrome Initial Visit SafeStep DME Low Top Air WalkerOssur Rebound Low Top Air WalkerAll SafeStep DME Available with custom logoPneumatic WalkersSuggested Code: L4360DMEPOS Fee Ceiling: $319.75
43 Posterior Night Splint Night Splint ~ Posterior or Dorsal Achillies Tendonitis with Plantar Flexion Contracture of the Ankle (718.47)Initial VisitOssur FormfitPosterior Night SplintSafeStep DME DorsalNight SplintOssur AirformDorsal Night SplintNight Splint ~ Posterior or DorsalSuggested Code: L4396DMEPOS Fee Ceiling: $184.82
44 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
45 Possible Diagnosis Codes: Metatarsal FracturePossible Diagnosis Codes:Stress fracture, unspecifiedFracture of the metatarsal bone
46 Non-Pnematic Low Top Walker DMEPOS Fee Ceiling: Patient pays Metatarsal Fracture:Initial visitSafeStep DMENon-Pnematic Low Top WalkerSuggested Code: L4386DMEPOS Fee Ceiling: $174.36Darco Med-Surg WalkerSuggested Code: L2999DMEPOS Fee Ceiling: Patient pays
47 Metatarsal Fracture: Follow up visit PowerStep ProTech Prefabricated OrthoticSuggested Code: L2999DMEPOS Fee Ceiling: Patient pays
48 Possible Diagnosis Codes: Flaccid Drop FootPossible Diagnosis Codes:Acquired deformity of foot and ankleHemiplegiaJoint derangement, ankle and footPeroneal muscle atrophy, Charcot Marie Tooth diseaseMultiple sclerosisPoliomyelitis, late effects
49 Flaccid Drop Foot : Initial Visit Euro International Peromax Suggested Code: L1951DMEPOS Fee Ceiling: $926
55 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.
56 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.
57 When can a person get another device? Upon examination and documentation of change in status. Medical justification is established chart notes.
58 ***Not responsible for typographical errors. 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.