Podiatry Coding & Billing Alert

Hint: The standard written order (SWO) must include specific elements.

In the recent webinar, “Lower Limb Orthosis,” Courtney Willis, part of the DME/A/B Outreach and Education team from the MAC Noridian, Courtney Willis, shared how podiatry practices can keep their foot orthotics (AFOs) claims in good shape. Expert tips include knowing the difference between their ankle-foot orthosis (AFO) and custom-fit orthotics and understanding the medical documentation requirements for the orthotics.

Read on to learn more.

Tip 1: Differentiate Between Prefab and Custom Orthotics

An AFO is a brace a patient wears on the lower leg and foot to support the ankle. An AFO holds the foot and ankle in the correct position and corrects a foot drop, Willis said.

An orthotic device, by definition, is “a rigid or semi-rigid device used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body,” Willis added.

An orthotic device can be either prefabricated or custom-fit.

Prefabricated orthotic device defined: Prefabricated orthotics, also known as “off the shelf,” are manufactured in quantity without a specific patient in mind.

Custom-fit orthotic device defined: On the other hand, custom-fit orthotics are made for a specific patient, starting with a basic material such as plastic, metal, leather, or cloth, Willis said. Custom-fit orthotics involve substantial modification to fit the specific patient.

Tip 2: Dig Into Custom-Fit Requirements

As mentioned, custom-fit orthotics are individually made for a specific patient, and no other patient will be able to use this item, Willis said.

Custom-fit orthotics also meet the following criteria:

• They are based on a positive model of the patient’s affected body part.
• They are “fabricated based on clinically-derived an rectified castings, tracings, measurements, and/or other images (such as X-rays) of the body part,” Willis said.
• They involve substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing before the patient is fit for the orthotic.

Documentation requirements for custom-fit orthotics: The treating physician must always document the medical necessity for a custom-fit orthotic versus a prefabricated orthotic, Willis said. The physician should be able to answer the following questions: (1) Why does the patient need a custom-fit orthotic and (2) Why would a prefabricated orthotic not meet this patient’s needs?

Tip 3: See Criteria for Non-Ambulatory Patients

Medicare will cover a static or dynamic positioning AFO as identified by codes L4396 (Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise) or L4397 (Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf) for non-ambulatory or minimally ambulatory patients under very specific circumstances. Either the patient must meet criteria 1-4 below or the patient must meet criterion 5:

1. Plantar flexion contracture of ankle with dorsiflexion on Passive Range of Motion (PROM) testing of at least ten degrees; and

2. Reasonable expectation of 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 component of therapy program, which includes active stretching of involved muscles and/or tendons

OR

5. The patient has plantar fasciitis

Tip 4: Search AFO Mandates for Ambulatory Patients

Under certain conditions, for ambulatory patients with weakness or deformity of the foot and ankle, Medicare will cover AFOs as described by the following codes:

• L1900 (Ankle foot orthosis (AFO), spring wire, dorsiflexion assist calf band, custom-fabricated)-L1990 (Ankle foot orthosis (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar ‘BK’ orthosis), custom-fabricated)
• L2106 (Ankle foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom-fabricated)- L2116 (Ankle foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment)
• L4350 (Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf)- L4361 (Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf)
• L4386 (Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise)-L4387 (Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf)
• L4631 (Ankle foot orthosis (AFO), walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated)

The coverage conditions for ambulatory patients include the following criteria, according to Willis:

• In the medical record, the treating physician includes a plan to move the patient to ambulatory status.
• The patient requires stabilization for medical reasons.
• The patient has the potential to benefit functionally from the AFO.

Custom-fit AFOs: Custom-fit AFOs for ambulatory patients will be covered when the above criteria are met, as well as one of the criteria below are met, Willis said:

1. The provider could not fit the patient with a prefabricated AFO; or
2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or
3. There is a need to control the knee, ankle, or foot in more than one plane; or
4. The patient has a documented neurological, circulatory, or orthopedic status; or
5. The patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.

Tip 5: Include These Elements on SWO

A standard written order (SWO) for an AFO should include the following information, per Willis:

• The patient’s name or Medicare Beneficiary Identifier (MBI)
• The order date
• A description of the item, which can be a general description, a HCPCS code, HCPCS code narrative, or a specific brand name or model number
• The quantity of the item to be dispensed
• The treating practitioner’s name or National Provider Identifier (NPI)
• The treating practitioner’s signature