Presentation on theme: "Diagnosis Specific DME Treatment Protocols and Charting Compliance Oklahoma Podiatric Medical Association May 11, 2012 Hal Ornstein, DPM, FASPS Chairman,"— Presentation transcript:
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 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. 1902 L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1902 ANKLE 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: L1906 DMEPOS 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 covered L1902 AFO, Gauntlet style L1906 AFO, Multiligamentous L4386 AFO, Non-pneumatic walking L4396 AFO, Plantarfascia night splint L4360 AFO, Pneumatic below knee L1971 AFO, With ankle joint L4350 AFO, Ankle control orthotics L1932 AFO, Dynamic L1951 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 2 & 3 Possible Diagnosis Codes: 729.5 Ankle pain and support 719.07 Effusion of joint, ankle, foot 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.01 Sprain and strain of ankle and foot, deltoid ligament 824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar
Ankle Sprain ~ Grades 2 & 3 Initial Visit Pneumatic Walker Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75 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
Severe Tarsal Tunnel Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 DMEPOS Fee Ceiling: $319.75 Ossur Rebound Low Top Air Walker SafeStep DME Low Top Air Walker All SafeStep DME Available with custom logo
Achillies Tendonitis with Plantar Flexion Contracture of the Ankle (718.47) Initial Visit Night Splint ~ Posterior or Dorsal Suggested Code: L4396 DMEPOS Fee Ceiling: $184.82 Ossur Formfit Posterior Night Splint Ossur Airform Dorsal 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, unspecified 825.25 Fracture of the metatarsal bone
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.