Diagnosis Specific DME Treatment Protocols SAM January 16, 2015 Hal Ornstein, DPM Chairman, AAPPM Howell, New Jersey Andrew Schneider, DPM Board of Trustees.

Diagnosis Specific DME Treatment Protocols SAM January 16, 2015 Hal Ornstein, DPM Chairman, AAPPM Howell, New Jersey Andrew Schneider, DPM Board of Trustees AAPPM Houston, Texas Cindy Pezza, PMAC Chair Assistants Section AAPPM

www.podiatrypresentations.com

Objectives To better understand the available information To better understand the role of treatment protocols and how to integrate additional durable medical equipment, maximizing patient compliance, outcome and practice revenue

Reasons To Follow These Protocols... Improved outcomes Easy to follow Medico-legal security Improved patient satisfaction Patient convenience Ease of inventorying Increase revenue (PVV) Consistent with standards of care

Disclaimer: Suggested codes are based on publicly available information and are offered as a convenience to physicians. The authors make no claims, promises or guarantees as to the availability of reimbursement for any of the suggested products. It is within the sole discretion of physicians to determine the appropriate billing code for a product as well as whether the use of a product complies with medical necessity and other documentation requirements of the payer. Actual reimbursement may vary. ***Not responsible for typographical errors.

Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally. When to use L Codes (basic coverage criteria)

AFOs that are custom-fabricated are covered for ambulatory patients when the basic coverage criteria listed and one of the following criteria are met: The patient could not be fit with a prefabricated AFO, or The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months), or There is a need to control the knee, ankle or foot in more than one plane, or The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions. When to use L Codes (cont)

Commonly used Prefabricated AFO Categories/DME HCPCS Codes L2999 Non covered L1902 AFO, Gauntlet style L1906 AFO, Multiligamentous L4386 AFO, Non-pneumatic walking L4396 AFO, Plantarfascia night splint L4360 AFO, Pneumatic below knee L1971 AFO, With ankle joint L4350 AFO, Ankle control orthotics L1932 AFO, Dynamic L1951 AFO, Spiral, plastic, other

www.dmepdac.com This is official Medicare DME site. Coding verification is the process that allows manufacturers/distributors to request a coding decision on a DMEPOS item

Ankle Sprain ~ Grade 1 Possible Diagnosis Codes: 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.00 Sprain and strain of ankle and foot, unspecified site 729.5 Pain in limb 719.07 Unspecified disorder of ankle and foot

Ankle Sprain ~ Grade 1 Visit One Ossur GameDay Suggested Code: L1902

Ankle Sprain Grades 2 and 3 Possible Diagnosis Codes: 729.5 Ankle pain and support 719.07 Effusion of joint, ankle, foot 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.01 Sprain and strain of ankle and foot, deltoid ligament 824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar Possible Diagnosis Codes: 729.5 Ankle pain and support 719.07 Effusion of joint, ankle, foot 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.01 Sprain and strain of ankle and foot, deltoid ligament 824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar

Ankle Sprain ~ Grades 2 & 3 Initial Visit Pneumatic Walker Suggested Code: L4360 Aircast FP Walker Ossur Rebound Air Walker Generic Low Top Air Walker Ossur Equalizer Premium Air Walker

Ankle Sprain ~ Grade 2 & 3 Follow up visit, 2 - 6 weeks Suggested Code: L1906 Careful, used to be L1971! Delayed Healing Healing Well Ossur Exoform Ossur Rebound Hinged Ankle Brace Ossur GameDay Suggested Code: L1902 Suggested Code: L1902

Ankle Instability Possible Diagnosis Codes: 718.31 RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT 845.00 Sprain and strain of ankle and foot, unspecified

A nkle Instability Initial Visit MildModerate Suggested Code: L1906 Ossur Rebound Hinged Ankle Brace Ossur Exoform Suggested Code: L1902 Ossur GameDay Suggested Code: L1902

Gait / Chronic A nkle Instability Moore Balance Brace Suggested L Codes: L1940, L2330, L2820 x2

Plantar Fasciitis Diagnosis Code: 728.71 Plantar fascial fibromatosis

Plantar fasciitis Initial Visit Aircast Airheel Suggested Code: L2999 Patient Pays Foot Steps Insert Suggested Code: L2999 Patient Pays

Plantar fasciitis Subsequent Visit Night Splint ~ Posterior or Dorsal Suggested Code: L4396 Ossur Formfit Posterior Night Splint Ossur Airform Dorsal Night Splint Darco Dorsal Night Splint

Criteria for L4396 An L4396 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met: 1. Plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsi-flexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture); and 2. Reasonable expectation of the 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 a component of a therapy program which includes active stretching of the involved muscles and/or tendons; or 5. The patient has plantar fasciitis (ICD-9 diagnosis code 728.71) *********NEWEST CRITERIA Device Must be adjustable******** http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=11517

Plantar fasciitis ~ Subsequent Visit Pneumatic Walker Suggested Code: L4360 Severe Aircast SP Walker Generic Low Top Air Walker

Posterior Tibialis Tendonitis Possible Diagnosis Codes: 726.72 Tibialis tendonitis 905.8 Late effect of tendon injury, sprain, strain

Posterior Tibialis Tendonitis Mild ~ Initial Visit Aircast Airlift PTTD Suggested Code: L1906 DMEPOS Fee Ceiling: $135 Foot Steps Insert Suggested Code: L2999 Patient Pays

Posterior Tibialis Tendonitis Moderate ~ Initial Visit Suggested Code: L1906 In order to bill L1971, ***PDAC letter is required *** Ossur Rebound Hinged Ankle Brace Donjoy Velocity ES

Posterior Tibial Tendonitis Severe ~ Initial Visit Pneumatic Walker Suggested Code: L4360 Aircast FP Walker Ossur Equalizer Premium Air Walker Ossur Rebound Air Walker Generic Air Walker

Posterior Tibial Tendonitis Subsequent Visit Aircast Airlift PTTD Suggested Code: L1902 Less Severe Donjoy Velocity ES More Severe Ossur Rebound Hinged Ankle Brace Suggested Code: L1906

Posterior Tibialis Tendon Rupture Stage 3 Possible Diagnosis Codes: 727.68 Rupture, tendon of foot and ankle, non-traumatic 728.4 Laxity of ligament 734 Flat foot, acquired

Posterior Tibialis Tendon Rupture ~ Stage 3 ~ Initial Visit Pneumatic Walker Suggested Code: L4360 Ossur Rebound Air Walker Generic Air WalkerAircraft FP Walker

Posterior Tibialis Rupture Stage 3 Subsequent Visit, if getting better Aircast Airlift PTTD Suggested Code: L1902 Less Severe Donjoy Velocity ES More Severe Ossur Rebound Hinged Ankle Brace Suggested Code: L1906

Posterior Tibialis Tendon Rupture ~ Stage 3 Subsequent Visit, if getting worse Arizona Standard AFO Suggested Codes: L1940, L2330, L2820

Post Op Bunionectomy, Metatarsal Osteotomy Possible Diagnosis Codes: 825.25 Fracture of the metatarsal bone 719.47 Pain joint, foot

Metatarsal Osteotomy Initial visit Non-Pneumatic Low Top Walker Suggested Code: L4386

Pediatric Fracture Possible Diagnosis Codes: 729.5 Ankle pain and support 719.07 Unspecified disorder of ankle and foot 845.02 Sprain and strain of ankle and foot, calcaneofibular 845.01 Sprain and strain of ankle and foot, deltoid ligament 824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar

Pediatric Fracture Initial Visit Pneumatic Walker, Pediatric or XS Adult Size Suggested Code: L4360 Ossur Rebound Air Walker Aircast XP Walker Bledsoe Wee Walker

Pediatric Fracture Follow up visit, 7 - 9 weeks Aircast Air-Stirrup, pediatric size Suggested Code: L4350

Tarsal Tunnel Syndrome Possible Diagnosis Codes: 355.5 Tarsal tunnel syndrome 719.47 Pain in joint, ankle, foot

Tarsal Tunnel Syndrome Initial Visit Mild Moderate Suggested Code: L1906 Ossur Exoform Suggested Code: L1902 Ossur GameDay Suggested Code: L1902 Ossur Rebound Hinged Ankle Brace

Severe Tarsal Tunnel Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast SP Walker Ossur Equalizer Low Top Air Walker Generic Low Top Air Walker

Severe Tarsal Tunnel Syndrome Subsequent Visit Ossur GameDay Suggested Code: L1902 Aircast Airlift PTTD Suggested Code: L1902

Peroneal Tendonitis Possible Diagnosis Code: 726.79 Enthesopathy of ankle and tarsus

Peroneal Tendonitis Initial Visit Mild to Moderate Ossur Game Day Suggested Code: L1902

Peroneal Tendonitis ~ Severe Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast SP Walker Ossur Rebound Air Walker Generic Low Top Air Walker Ossur Equalizer Premium Air Walker

Peroneal Tendonitis Subsequent Visit Severe Ossur GameDay Suggested Code: L1902

Sinus Tarsi Syndrome Possible Diagnosis Codes: 726.79 Enthesopathy of ankle and tarsus 719.47 Pain in joint, ankle, foot

Sinus Tarsi Syndrome Initial Visit Mild Moderate Suggested Code: L1906 Ossur Exoform Suggested Code: L1902 Ossur GameDay Suggested Code: L1902 Ossur Rebound Hinged Ankle Brace

Sinus Tarsi Syndrome Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast SP Walker Ossur Equalizer Low Top Air Walker Generic Low Top Air Walker

Sinus Tarsi Syndrome ~ Severe Subsequent Visit Ossur GameDay Suggested Code: L1902

Achilles Tendonitis Achilles Tendon Rupture Possible Diagnosis Codes: 845.09 Achilles tendon strain, rupture 726.71 Achilles tendonitis

Achilles Tendonitis ~ Achilles Tendon Tear Initial Visit Pneumatic Walkers Suggested Code: L4360 Aircast FP Walker Generic Below the Knee Air Walker Ossur Rebound Air Walker

Achilles Tendonitis Initial Visit Night Splint ~ Posterior or Dorsal Suggested Code: L4396 Generic Posterior Night Splint Darco Dorsal Night Splint

Achilles Tendonitis ~ Achilles Tendon Tear Subsequent / Follow up visit Ossur GameDay Suggested Code: L1902

Metatarsal Fracture Possible Diagnosis Codes: 733.94 Stress fracture, unspecified 825.25 Fracture of the metatarsal bone

Metatarsal Fracture Initial visit Non-Pneumatic Low Top Walker Suggested Code: L4386

Metatarsal Fracture Follow up visit Foot Steps Prefabricated Orthotic Suggested Code: L2999 Patient pays

Flaccid Drop Foot Possible Diagnosis Codes: 736.79 Acquired deformity of foot and ankle 438.20 Hemiplegia 719.97 Joint derangement, ankle and foot 356.1 Peroneal muscle atrophy, Charcot Marie Tooth disease 340 Multiple sclerosis 138 Poliomyelitis, late effects

Flaccid Drop Foot ~ Initial Visit Euro International Peromax Suggested Code: L1951

Footsteps Medical Grade Orthotics

www.aappm.com Indications for use of Over-the-Counter Arch Supports while waiting for custom orthotic devices for mild conditions second pair for orthotic wearers for infrequently worn shoes (continuous therapy) all diabetics not in need of custom orthotic devices affordable option for those who refuse orthotics www.aappm.com

Limit options and Recommend the Right Style

You can Google that! Patients will seek to find your products elsewhere at a discounted rate Customization shows your patients that your products are physician only/ Medical grade available ONLY through your practice.

Thank you! Andrew Schneider, DPM [email protected] Cindy Pezza, PMAC [email protected] Hal Ornstein, DPM [email protected]

Diagnosis Specific DME Treatment Protocols SAM January 16, 2015 Hal Ornstein, DPM Chairman, AAPPM Howell, New Jersey Andrew Schneider, DPM Board of Trustees.

Documents

foot slide

l1902 slide

anklefoot orthoses afo

ankle sprain

codes cont slide

ankle joint l4350 afo

covered l1902 afo

strain of ankle