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Diagnosis Specific DME Treatment Protocols SAM January 16, 2015 Hal Ornstein, DPM Chairman, AAPPM Howell, New Jersey Andrew Schneider, DPM Board of Trustees.

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Presentation on theme: "Diagnosis Specific DME Treatment Protocols SAM January 16, 2015 Hal Ornstein, DPM Chairman, AAPPM Howell, New Jersey Andrew Schneider, DPM Board of Trustees."— Presentation transcript:

1 Diagnosis Specific DME Treatment Protocols SAM January 16, 2015 Hal Ornstein, DPM Chairman, AAPPM Howell, New Jersey Andrew Schneider, DPM Board of Trustees AAPPM Houston, Texas Cindy Pezza, PMAC Chair Assistants Section AAPPM

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3 Objectives To better understand the available information To better understand the role of treatment protocols and how to integrate additional durable medical equipment, maximizing patient compliance, outcome and practice revenue

4 Reasons To Follow These Protocols... Improved outcomes Easy to follow Medico-legal security Improved patient satisfaction Patient convenience Ease of inventorying Increase revenue (PVV) Consistent with standards of care

5 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 payer. Actual reimbursement may vary. ***Not responsible for typographical errors.

6 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. When to use L Codes… (basic coverage criteria)

7 AFOs that are custom-fabricated are covered for ambulatory patients when the basic coverage criteria listed and one of the following criteria are met: The patient could not be fit with a prefabricated AFO, or The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months), or There is a need to control the knee, ankle or foot in more than one plane, or The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions. When to use L Codes… (con’t)

8 Commonly used Prefabricated 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

9 This is official Medicare DME site. Coding verification is the process that allows manufacturers/distributors to request a coding decision on a DMEPOS item

10 Ankle Sprain ~ Grade 1 Possible Diagnosis Codes: Sprain and strain of ankle and foot, calcaneofibular Sprain and strain of ankle and foot, unspecified site Pain in limb Unspecified disorder of ankle and foot

11 Ankle Sprain ~ Grade 1 Visit One Ossur GameDay Suggested Code: L1902

12 Ankle Sprain Grades 2 and 3 Possible Diagnosis Codes: 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 Possible Diagnosis Codes: 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

13 Ankle Sprain ~ Grades 2 & 3 Initial Visit Pneumatic Walker Suggested Code: L4360 Aircast FP Walker Ossur Rebound Air Walker Generic Low Top Air Walker Ossur Equalizer Premium Air Walker

14 Ankle Sprain ~ Grade 2 & 3 Follow up visit, weeks Suggested Code: L1906 Careful, used to be L1971! Delayed Healing Healing Well Ossur Exoform Ossur Rebound Hinged Ankle Brace Ossur GameDay Suggested Code: L1902 Suggested Code: L1902

15 Ankle Instability Possible Diagnosis Codes: RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT Sprain and strain of ankle and foot, unspecified

16 A nkle Instability Initial Visit MildModerate Suggested Code: L1906 Ossur Rebound Hinged Ankle Brace Ossur Exoform Suggested Code: L1902 Ossur GameDay Suggested Code: L1902

17 Gait / Chronic A nkle Instability Moore Balance Brace Suggested L Codes: L1940, L2330, L2820 x2

18 Plantar Fasciitis Diagnosis Code: Plantar fascial fibromatosis

19 Plantar fasciitis Initial Visit Aircast Airheel Suggested Code: L2999 Patient Pays Foot Steps Insert Suggested Code: L2999 Patient Pays

20 Plantar fasciitis Subsequent Visit Night Splint ~ Posterior or Dorsal Suggested Code: L4396 Ossur Formfit Posterior Night Splint Ossur Airform Dorsal Night Splint Darco Dorsal Night Splint

21 Criteria for L4396… An L4396 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria or criterion 5 is met: 1. Plantar flexion contracture of the ankle (ICD-9 diagnosis code ) with dorsi-flexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture); and 2. Reasonable expectation of the ability to correct the contracture; and 3. Contracture is interfering or expected to interfere significantly with the patient's functional abilities; and 4. Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons; or 5. The patient has plantar fasciitis (ICD-9 diagnosis code ) *********NEWEST CRITERIA – Device Must be adjustable********

22 Plantar fasciitis ~ Subsequent Visit Pneumatic Walker Suggested Code: L4360 Severe Aircast SP Walker Generic Low Top Air Walker

23 Posterior Tibialis Tendonitis Possible Diagnosis Codes: Tibialis tendonitis Late effect of tendon injury, sprain, strain

24 Posterior Tibialis Tendonitis Mild ~ Initial Visit Aircast Airlift PTTD Suggested Code: L1906 DMEPOS Fee Ceiling: $135 Foot Steps Insert Suggested Code: L2999 Patient Pays

25 Posterior Tibialis Tendonitis Moderate ~ Initial Visit Suggested Code: L1906 In order to bill L1971, ***PDAC letter is required *** Ossur Rebound Hinged Ankle Brace Donjoy Velocity ES

26 Posterior Tibial Tendonitis Severe ~ Initial Visit Pneumatic Walker Suggested Code: L4360 Aircast FP Walker Ossur Equalizer Premium Air Walker Ossur Rebound Air Walker Generic Air Walker

27 Posterior Tibial Tendonitis Subsequent Visit Aircast Airlift PTTD Suggested Code: L1902 Less Severe Donjoy Velocity ES More Severe Ossur Rebound Hinged Ankle Brace Suggested Code: L1906

28 Posterior Tibialis Tendon Rupture Stage 3 Possible Diagnosis Codes: Rupture, tendon of foot and ankle, non-traumatic Laxity of ligament 734 Flat foot, acquired

29 Posterior Tibialis Tendon Rupture ~ Stage 3 ~ Initial Visit Pneumatic Walker Suggested Code: L4360 Ossur Rebound Air Walker Generic Air WalkerAircraft FP Walker

30 Posterior Tibialis Rupture Stage 3 Subsequent Visit, if getting better Aircast Airlift PTTD Suggested Code: L1902 Less Severe Donjoy Velocity ES More Severe Ossur Rebound Hinged Ankle Brace Suggested Code: L1906

31 Posterior Tibialis Tendon Rupture ~ Stage 3 Subsequent Visit, if getting worse Arizona Standard AFO Suggested Codes: L1940, L2330, L2820

32 Post Op Bunionectomy, Metatarsal Osteotomy Possible Diagnosis Codes: Fracture of the metatarsal bone Pain joint, foot

33 Metatarsal Osteotomy Initial visit Non-Pneumatic Low Top Walker Suggested Code: L4386

34 Pediatric Fracture Possible Diagnosis Codes: Ankle pain and support Unspecified disorder of ankle and 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

35 Pediatric Fracture Initial Visit Pneumatic Walker, Pediatric or XS Adult Size Suggested Code: L4360 Ossur Rebound Air Walker Aircast XP Walker Bledsoe Wee Walker

36 Pediatric Fracture Follow up visit, weeks Aircast Air-Stirrup, pediatric size Suggested Code: L4350

37 Tarsal Tunnel Syndrome Possible Diagnosis Codes: Tarsal tunnel syndrome Pain in joint, ankle, foot

38 Tarsal Tunnel Syndrome Initial Visit Mild Moderate Suggested Code: L1906 Ossur Exoform Suggested Code: L1902 Ossur GameDay Suggested Code: L1902 Ossur Rebound Hinged Ankle Brace

39 Severe Tarsal Tunnel Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast SP Walker Ossur Equalizer Low Top Air Walker Generic Low Top Air Walker

40 Severe Tarsal Tunnel Syndrome Subsequent Visit Ossur GameDay Suggested Code: L1902 Aircast Airlift PTTD Suggested Code: L1902

41 Peroneal Tendonitis Possible Diagnosis Code: Enthesopathy of ankle and tarsus

42 Peroneal Tendonitis Initial Visit Mild to Moderate Ossur Game Day Suggested Code: L1902

43 Peroneal Tendonitis ~ Severe Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast SP Walker Ossur Rebound Air Walker Generic Low Top Air Walker Ossur Equalizer Premium Air Walker

44 Peroneal Tendonitis Subsequent Visit Severe Ossur GameDay Suggested Code: L1902

45 Sinus Tarsi Syndrome Possible Diagnosis Codes: Enthesopathy of ankle and tarsus Pain in joint, ankle, foot

46 Sinus Tarsi Syndrome Initial Visit Mild Moderate Suggested Code: L1906 Ossur Exoform Suggested Code: L1902 Ossur GameDay Suggested Code: L1902 Ossur Rebound Hinged Ankle Brace

47 Sinus Tarsi Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast SP Walker Ossur Equalizer Low Top Air Walker Generic Low Top Air Walker

48 Sinus Tarsi Syndrome ~ Severe Subsequent Visit Ossur GameDay Suggested Code: L1902

49 Achilles Tendonitis Achilles Tendon Rupture Possible Diagnosis Codes: Achilles tendon strain, rupture Achilles tendonitis

50 Achilles Tendonitis ~ Achilles Tendon Tear Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast FP Walker Generic Below the Knee Air Walker Ossur Rebound Air Walker

51 Achilles Tendonitis Initial Visit Night Splint ~ Posterior or Dorsal Suggested Code: L4396 Generic Posterior Night Splint Darco Dorsal Night Splint

52 Achilles Tendonitis ~ Achilles Tendon Tear Subsequent / Follow up visit Ossur GameDay Suggested Code: L1902

53 Metatarsal Fracture Possible Diagnosis Codes: Stress fracture, unspecified Fracture of the metatarsal bone

54 Metatarsal Fracture Initial visit Non-Pneumatic Low Top Walker Suggested Code: L4386

55 Metatarsal Fracture Follow up visit Foot Steps Prefabricated Orthotic Suggested Code: L2999 Patient pays

56 Flaccid Drop Foot Possible Diagnosis Codes: Acquired deformity of foot and ankle Hemiplegia Joint derangement, ankle and foot Peroneal muscle atrophy, Charcot Marie Tooth disease 340 Multiple sclerosis 138 Poliomyelitis, late effects

57 Flaccid Drop Foot ~ Initial Visit Euro International Peromax Suggested Code: L1951

58 Footsteps Medical Grade Orthotics

59 Indications for use of Over-the-Counter Arch Supports while waiting for custom orthotic devices for mild conditions second pair for orthotic wearers for infrequently worn shoes (continuous therapy) all diabetics not in need of custom orthotic devices affordable option for those who refuse orthotics

60 Limit options and Recommend the Right Style

61 You can “Google” that! Patients will seek to find your products elsewhere at a discounted rate Customization shows your patients that your products are “physician only”/ “Medical grade” available ONLY through your practice.

62 Thank you! Andrew Schneider, DPM Cindy Pezza, PMAC Hal Ornstein, DPM

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