By Virginia Torsch, AOPA Government Affairs Department

DMERC medical policy can be confusing. Cut through the red tape to ensure you get paid for the devices you provide.

Coverage policies are established for lower-limb prosthetics, orthopedic footwear, AFOs/KAFOs, spinal orthoses and therapeutic shoes for persons with diabetes.

This article covers aspects of the AFO/KAFO medical policy you need to know.

What is medical policy?

The content of medical coverage policies is found in two separate documents, a local coverage determination (LCD) and an accompanying policy article. Together, both documents constitute the "medical policy." You should be familiar with the content of the LCD and the policy article.

This two-part format, effective December 2003, replaces the more familiar single local medical review policy (LMRP) with both national medical coverage policy and local coverage criteria for a class of items (for example AFOs/KAFOs).

Know the LCD

The LCD discusses coverage in terms of medical necessity—is an item reasonable and medically necessary?

The LCD also contains the list of HCPCS codes and modifiers it covers, the ICD-9 diagnosis codes that support medical necessity for the items or services, the documentation requirements and a history of all revisions to the medical coverage policy since its inception.

Know the policy article

The policy article accompanying the LCD identifies situations where an item is not covered by a Medicare benefit category—denied as "non covered" rather than "not medically necessary." It also identifies situations when an item may be denied as "not separately payable."

Coding guidelines and a repeat of the list of HCPCS codes and modifiers found in the LCD are also in the policy article.

With two separate documents, it's tough to grasp when an AFO/KAFO will be paid by Medicare.

First, you should know the Medicare definition of a brace since Medicare will deny as "non covered" any items not meeting this definition.

Define a "brace"

As noted in the policy article for AFOs/KAFOs, Medicare defines a brace as 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.

The device must provide support and counterforce, defined by Medicare as a force in a defined direction of magnitude at least as great as a rigid or semi-rigid support, on the body part it is being used to brace.

If Medicare believes an AFO or KAFO is not being used for this defined purpose, the claim will be denied as "non covered."

For example, AFOs described by codes L4360 and L4386 ("walking boots") prescribed to treat pressure ulcers or edema are not covered by Medicare. This is because the AFO is not being used to support a weak or deformed body member.

If a walking boot is used for immobilization to treat an orthopedic condition or after orthopedic surgery, however, it will be covered by Medicare under the brace benefit.

Likewise, Medicare will not cover a static AFO (L4396) and replacement interface (L4392) or a foot drop splint/ recumbent positioning device (L4398) or replacement interface (L4394) if they have been prescribed solely for the prevention or treatment of heel pressure ulcer. While Medicare will treat these ulcers in other ways, it will not cover braces used solely for this purpose.

Static AFOs

Specific coverage criteria on the medical necessity requirements for AFOs and KAFOs is outlined in the LCD.

In the policy article, Medicare defines a static AFO (L4396) as a prefabricated ankle-foot orthosis which has the following characteristics:

• Accommodates either plantar fasciitis or an ankle with a plantar flexion contracture up to 45 degrees;
• Applies a dorsiflexion force to the ankle;
• Used by a patient who is minimally ambulatory or nonambulatory; and
• Has a soft interface.

The LCD states that Medicare will cover such a static AFO for a nonambulatory patient who meets all of the following criteria:

• Has a plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsiflexion on a passive range of motion testing of at least 10 degrees;
• Has a reasonable expectation of the ability to correct the contracture of the ankle;
• The contracture is interfering significantly or is expected to interfere significantly with the patient's functional abilities; and
• The AFO is used as a component of a therapy program which includes active stretching of the involved muscles and tendons.
• Medicare will also cover a static AFO for a nonambulatory patient with plantar fasciitis (ICD-9 diagnosis code 728.71).

If the static AFO is used to treat a plantar flexion contracture, you must measure and document the pretreatment passive range of motion. You must also document a stretching program carried out by professional staff or a caregiver.

Replacement interfaces

Medicare will also cover a replacement interface (L4392) as long as the patient continues to meet the coverage criteria for the static AFO. Medicare will only pay for one replacement interface per six months (total of two per year).

Medicare will deny a static AFO and replacement interface as not medically necessary if the contracture is fixed or if the device is being used for a patient with foot drop but no ankle flexion contracture.

Medicare will also deny as not medically necessary a component of a static AFO that is used to address positioning of the knee or hip because Medicare does not believe the effectiveness of this type of component has been established.

Medicare will also deny a foot drop splint/recumbent positioning device or replacement interface as not medically necessary for a nonambulatory patient with foot drop. Medicare believes there are more appropriate treatment modalities than the use of an orthosis.

Ambulatory AFOs/KAFOs

The LCD states that Medicare will pay for AFOs described by L1900-1990, L2106-L2116, L4350, L4360 and L4386 for ambulatory patients with weakness or deformity of the foot and ankle who require stabilization and have the potential to benefit functionally.

Medicare will also pay for KAFOs, described by L200-2039, L2126-L2136 and L4370, for ambulatory patients eligible for AFOs, who also require additional knee stability.

Medicare will cover molded-to-patient model or custom-fabricated AFOs and KAFOs if:

• The patient can't be fit with a prefabricated AFO/KAFO.
• The medical condition is expected to be permanent or last more than six months.
• There is a need to control the knee, ankle or foot in more than one plane.
• The patient has a documented neurological, circulatory or orthopedic condition that requires custom fabricating over a model to prevent tissue injury.
• The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

For custom-fabricated devices, be sure to document evidence are supporting which of these five criteria are met. If the patient only meets the criteria for a prefabricated, custom-fitted orthosis, Medicare will "down code" the claim and pay only the least costly medically appropriate alternative.

Refer to the policy article for Medicare definitions of a prefabricated, custom-fabricated or molded-to-patient model orthosis.

Additions to AFOs or KAFOs, described by L2180-L2550 and L2750-L2830, will only be covered if the base orthosis is covered and if the addition is medically necessary.

Read the policy article

The policy article contains additional coding guidelines you should know.

For instance, Medicare will not pay for L2860 (concentric adjustable torsion style mechanism). Prefabricated or custom-fabricated AFOs/KAFOs containing this type of mechanism in the knee or ankle joint that are being used to treat a joint contracture should be coded as E1810 or E1815.

If the device is being used to provide an assist function to the joint motion during ambulation, however, the torsion style mechanism should be coded as L2999.

Repairs and replacements

Specific information on repairs and replacements can also be found in the policy article.

Medicare will cover replacement of a complete orthosis or a component of an orthosis due to loss, a significant change in the patient's condition or irreparable accidental damage if the device is still medically necessary.

Medicare will not pay for replacement of an orthosis due to normal wear and tear if the device is less than five years old.

If you are replacing a component that has its own L code—for example, replacement interfaces described by L4392 or L4394—do not use L4205 for the labor of replacing that component.

You can only use L4205 for the labor involved in repairing an orthotic device or for replacing a component that is described by L4210 (minor parts).

Get paid

These are the major provisions of the LCD on AFOs/KAFOs you need to know to get your claims paid. CMS and the DMERCs occasionally publish transmittals and bulletins amplifying the provisions in the LCDs and accompanying policy articles, so you should watch for those, too.

Medicare expects you to keep up with all of these, so it is wise to pay attention to Medicare policy bulletins and transmittals.

Know, too, that the AOPA staff is committed to keeping you up to speed on this information so you can be reimbursed appropriately for your work.

Virginia Torsch is the assistant director of reimbursement services for the American Orthotic & Prosthetic Association (AOPA). AOPA is a not-for-profit trade association providing O&P-specific business services and products for professionals. Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession. Questions? Call (571) 431-0876 or visit www.AOPAnet.org.