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
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www.podiatrypresentations.com
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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
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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
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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.
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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)
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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)
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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
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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
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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 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
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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
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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
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Ankle Instability Possible Diagnosis Codes: 718.31 RECURRENT
DISLOCATION OF ANKLE AND FOOT JOINT 845.00 Sprain and strain of
ankle and foot, unspecified
Plantar fasciitis Initial Visit Aircast Airheel Suggested Code:
L2999 Patient Pays Foot Steps Insert Suggested Code: L2999 Patient
Pays
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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
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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
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Plantar fasciitis ~ Subsequent Visit Pneumatic Walker Suggested
Code: L4360 Severe Aircast SP Walker Generic Low Top Air
Walker
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Posterior Tibialis Tendonitis Possible Diagnosis Codes: 726.72
Tibialis tendonitis 905.8 Late effect of tendon injury, sprain,
strain
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
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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
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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
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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
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
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Pediatric Fracture Initial Visit Pneumatic Walker, Pediatric or
XS Adult Size Suggested Code: L4360 Ossur Rebound Air Walker
Aircast XP Walker Bledsoe Wee Walker
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
Sinus Tarsi Syndrome Initial Visit Pneumatic Walkers Suggested
Code: L4360 Aircast SP Walker Ossur Equalizer Low Top Air Walker
Generic Low Top Air Walker
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Sinus Tarsi Syndrome ~ Severe Subsequent Visit Ossur GameDay
Suggested Code: L1902
Metatarsal Fracture Follow up visit Foot Steps Prefabricated
Orthotic Suggested Code: L2999 Patient pays
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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
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Flaccid Drop Foot ~ Initial Visit Euro International Peromax
Suggested Code: L1951
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Footsteps Medical Grade Orthotics
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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
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Limit options and Recommend the Right Style
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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.