Presentation on theme: "Diagnosis Specific DME Treatment Protocols and Charting Compliance North Carolina Foot and Ankle Society June 15, 2012 Myrtle Beach, South Carolina Hal."— Presentation transcript:
Diagnosis Specific DME Treatment Protocols and Charting Compliance North Carolina Foot and Ankle Society June 15, 2012 Myrtle Beach, South Carolina 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."
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
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
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. To provide support in at least two planes. 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
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