Podiatry Coding & Billing Alert

Always ensure the AFO documentation meets general DME requirements.

A reader recently wrote in, asking which details a provider should include in the medical documentation for durable medical equipment (DME) items like ankle-foot orthoses (AFOs). Reporting AFOs can be tricky because you must know if the provider ordered a custom-fit orthotic versus an off-the-shelf (OTS) orthotic. You must also understand which modifiers you can append to your claim.

When it comes to knowing what’s appropriate in the medical record documentation for AFOs, much depends on your specific MAC, explains Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan. Each Medicare company has its own policy and local coverage determination (LCD) you must follow.

Editor’s note: The requirements for AFOs used during ambulation may differ from those not used during ambulation. You should always follow your MAC’s specific LCD and contact your payers if you have any questions.

Take a look at some examples of details you should look for in AFO documentation based upon the LCD L33686, which both MACs CGS and Noridian follow.

AFOs Covered Under This Benefit

In general, for podiatry, Medicare will not cover foot orthotics unless they are attached to a lower extremity support or brace such as an AFOs, according to Beresh.

The Medicare Braces Benefit covers both AFOs and knee-ankle foot orthoses (KAFOs), according to policy article A52457. To qualify for coverage under this benefit, the orthotic must either be a rigid or semi-rigid device. Providers prescribe these devices for patients to support “a weak or deformed body member” or to restrict or eliminate motion in a diseased or injured part of the body.

Bottom line: If the orthotic is not sufficiently rigid to provide the needed immobilization or support for the patient, then it does not meet the statutory definition of the Braces Benefit and will be considered “statutorily noncovered,” with no benefit.

Delve into Custom-Fit AFO Documentation Requirements

Grasping all of the documentation requirements for AFOs can be challenging because not only must you meet the general documentation DME requirements, but you must also meet certain policy article A52457 requirements, as well.

General DME documentation requirements: When it comes to general documentation requirements for DME items, suppliers must make sure there are prescription (orders), medical record information, correct coding, and proof of delivery.

Code A52457 documentation requirements: As you read policy article A52457, the documentation requirements for AFOs can quickly appear complicated, especially for custom-fit devices. Take a look at the following details a provider should include in the documentation for custom-fit orthotics:

• On the claim line, the supplier must include the ICD-10 code for custom-fit 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) and 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).
• For custom-fit orthotics, represented by L1904, L1907, L1920, L1940-L1950, L1960, L1970, L1980-L2034, L2036-L2038, L2106-L2108, L2126-L2128, and L4631, your medical documentation must support the medical necessity of a custom-fit orthotic versus an OTS orthotic. The orthotist or prosthetist should be able to support this information in their records. This information must be available upon request.
• Custom-fit orthotics are those that require substantial modification by a qualified practitioner. Some examples of custom-fit orthotics include L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4360, L4386, and L4396. When you bill any of these codes, make sure the documentation includes a detailed description of the modifications that were necessary at the time of the orthosis fitting. You must also be able to supply this information upon request.

In addition to the above documentation requirements for custom-fit orthotics, suppliers must also follow certain rules. They are as follows:

• The supplier must provide the patient with the particular device the ordering physician specified.
• The supplier should ensure that the ordering physician’s medical record justifies the need for the custom-fit orthotic versus the OTS orthotic.
• The supplier should only bill the HCPCS code that accurately reflects the type of orthosis and the appropriate level of fitting.

The supplier should have detailed documentation in his medical »»documentation supporting the billed.

Don’t Forget These Modifiers on AFO Claims

Suppliers should append modifier KX (Requirements specified in the medical policy have been met) to the AFO/KAFO base and additional codes only if they have met all of the coverage criteria outlined in L33686. The supplier must also be able to show evidence that he met all of the coverage requirements if his DME MAC requests this information.

On the other hand, if the supplier has not met all of the criteria in the coverage indications section of L33686, he should append modifiers GA (Waiver of liability statement issued as required by payer policy, individual case) or GZ (Item or service expected to be denied as not reasonable and necessary) to the appropriate code.

If the supplier expects Medicare will deny his claim based upon medical necessity, he must enter modifier GA on the claim line if he has obtained a properly executed Advance Beneficiary Notice (ABN). If the supplier does not obtain a valid ABN, then he should enter modifier GZ on the claim line.