Durable Medical Equipment and Coding in Sports Medicine

Fig. 35.1

L3000

L3020: This device is also molded to a patient model but does not have a heel cup nor is it posted (Fig. 35.2).

Fig. 35.2

L3020

L3030: This is a device molded directly to a patient’s foot (Fig. 35.3). Therefore if a cast is not made of the foot, clearly this is not an appropriate selection.

Fig. 35.3

L3030

Orthosis Modifications

There are various HCPCS codes for orthosis repairs in the code range L4205–4210. Most orthotic companies will offer some type of guarantee for their products for premature breakage or incorrect prescription, As far as repairs, many insurance carriers do not pay for such services. Adjustments to the orthoses such as modifying the post, adding modifying forefoot extensions, and grinding down a rough area may not be payable separately. You could charge the patient directly for these repairs.

Sending orthoses back for minor repairs can be expensive and time consuming, plus the patient does not have the device. As a practice management tool, being able to perform minor repairs may be a great practice builder. Patients like the efficiency of having you repair the device promptly vs. a week or more wait if the orthosis is sent back to the orthotics lab. During this time the patient is without the use and benefit of the orthotic device. Plus this allows you an opportunity to review the orthosis and consider additional changes/modifications; see if the patient would benefit from a second pair of orthoses or possibly attempt other non-orthosis-related treatments, i.e., physical therapy for some residual pains.

There are several modifications that can be made to orthoses and shoes listed in HCPCS code range L3300–3649 and for AFO type devices HCPS codes L1900–2999. Again, these may or may not be payable. Clearly document why modifications need to be made.

E/M Services with Regard to Orthosis Management

Be clear in your chart; note the basis for the office encounter. If the patient came in solely to have the orthosis adjusted because there was a sharp edge or it was a bit too long and irritating the patient, some insurance may not pay for this as it may be deemed included within the orthosis fee allowance. No office visit may be allowed in that regard as there is no E/M service performed. Contrast this with the patient returning for evaluation of their plantar fasciitis, which is improving, but reached a plateau. In the latter case the E/M service would be allowed as you are addressing the plantar fasciitis, possibly changing treatment algorithm and/or adjusted the orthosis or post the device to try to increase the control of the orthosis to make it more effective.

Therapeutic Shoes for Diabetics

Custom-molded shoes or extra-depth shoes with custom inserts are covered for qualifying diabetics.

Coverage per calendar year:

One pair of custom shoes and two additional pairs of inserts (excluding the one pair that came with the shoe), or
One pair of extra-depth shoes and three pairs of inserts (excluding the pair that came with the shoes). A depth shoe definition is one that allows for a 3/16 insole leather and has a form of closure (laces or Velcro). It must be available in full and half sizes and in at least three widths.
Substitutions: One may substitute a pair of inserts for rocker bottom soles, metatarsal bars, wedges, offset heels, flared heels, or Velcro closures. This is not an exhaustive list rather the most common shoe modifications.
Extra insoles can be covered pending verification in writing.

Certification:

A M.D. or D.O. who is responsible for treating the patient’s diabetes must certify the need for diabetic shoes. (A podiatrist or orthopedist cannot certify.)
A podiatrist may prescribe and furnish diabetic shoes.

Coverage Criteria:

There must be documentation in the chart of one or more of the following conditions to warrant coverage under this program:

Peripheral neuropathy with evidence of callus formation
History of pre-ulcerative calluses
History of previous ulceration
Foot deformity
Previous amputation of the foot or part of the foot
Poor circulation

Payment:

Payment is limited to 80% of the reasonable charge up to a limited amount. If the sole purpose of the visit is to fit or dispense the shoes, no office visit is payable separately. Starting in 2005, the fee schedule will change for reimbursement and fall under the DME fee schedule.

Misc:

If the patient has a leg amputation, still bill for one pair of shoes but only for one (side) insole. Otherwise dispense and bill for the three insoles at the time the shoes are dispensed.

Codes:

Custom shoe A5501 (diabetic)

Depth shoe A5500 (diabetic)

Prefab insoles (not heat molded) A5510 (diabetic)

Prefab insoles (heat molded) A 5512 (diabetic)

Custom-molded insoles A5513 (diabetic)

Longitudinal insoles with arch and filler for amputated portion foot L5000

NOTE: The above codes apply to diabetics in need of a protective shoe with various insole choices. A diabetic who does not meet the above criteria and who may need a “standard” orthosis (i.e. L3000–L3030 for plantar fasciitis) would not qualify for coverage under this program.

Cam Walker/Braces

The definition of a brace is a rigid or semirigid device used for the purpose of

Supporting weak or deformed body member or restricting or eliminating motion in diseased or injured part of body
Must provide support and a counterforce on a limb or body part that it is being used to brace

Some of the more common HCPCS codes for AFOs include:

AFOs, codes

L1900, L1902-L1990, L2106–L2116, L4350, L4360, L4386, and L4631
KAFOs, codes

L2000–L2038, L2126–L2136, and L4370

Coverage for these devices varies depending on if the patient is ambulatory or not and if the device is a custom-fabricated device or a prefabricated device. As always, documentation is important. Some basic points to document are whether the patient is ambulatory or nonambulatory and why there is a need for a custom-fabricated vs. a prefabricated device.

There needs to be a detailed written order in your chart. If you are sending the patient out to an orthotist, a separate RX would be required. Depending on your DME carrier, if you are both prescribing and dispensing the device the written order can be part of your chart note. Some may still require a separate order. Regardless the following information needs to be listed on the RX or within your chart note:

Provide the product that is specified by the ordering physician
Type of orthosis dispensed
Written order
Proof of delivery
Medical records
- Documentation of the patient’s condition
- Documentation to support the medical necessity of a custom vs. prefabricated device
- Why a prefabricated device would not meet the patient’s needs
- Method of fitting and/or fabrication (OTS or custom fitted
Beneficiary Documentation or ABN
Use the code that most accurately reflects both the type of orthosis and the appropriate level of fitting

Ambulatory vs. Nonambulatory Patients

Ambulatory Patients

AFO/KFO items are covered for AMBULATORY patients when the patient is:

Ambulatory (or plan to move to an ambulatory status must be documented in medical record)

This is an important point. There has been an issue in the past with some Medicare DME carriers where cam walkers were being denied if the patient was non-weight bearing even for a short period of time. CMS interpreted this temporary non-weight-bearing status to mean that the patient was nonambulatory and hence the device would not be covered. Therefore make sure that your chart states that the patient will be transitioning to a weight-bearing status.