Podiatry Coding & Billing Alert

Question: The podiatrist prescribed the AFO represented by L2112 for a patient. Can you help us figure out what information we need in the documentation? Noridian is our MAC.

Pennsylvania Subscriber

Answer: Code L2112 (Ankle foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment) is an example of a custom-fit ankle-foot orthotic (AFO). When you bill this code, you must ensure that your medical documentation includes a detailed description of the modifications that were necessary at the time of the orthosis fitting.

Don’t forget: For the AFO to be considered custom-fit, it must have undergone substantial modification for fitting at the time of delivery to provide an individualized fit for the patient. Examples include trimming, bending, and molding the AFO. Additionally, only certain individuals are qualified to fit the patient for a custom-fit orthotic. These people include either an individual whom the American Board for Certification in Orthotics and Prosthetics, Inc. or the Board for Orthotist/Prosthetist Certification has certified OR a person who has the equivalent of specialized training in providing orthotics such as a physician, treating practitioner, occupational therapist, or physical therapist.

Details needed: For custom-fit devices, the provider must include a complete and clear description of the device, as well as a breakdown of charges.

Supplier info: If your podiatrist is the supplier for the AFO, he must make sure there are prescription (orders), medical record information, correct coding, and proof of delivery.

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

Modifiers: Don’t forget there are modifiers you must append to AFO claims, as well. Suppliers should append modifier KX (Requirements specified in the medical policy have been met) to the AFO base and additional codes only if they have met all of the coverage criteria outlined in LCD.

On the other hand, if the supplier has not met all of the criteria in the coverage indications section of the LCD, 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.