AFOs for Treatment of Lower Extremity Ulcers

According to Local Coverage Article: Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457) AFOs may be medically necessary when the brace is rigid or semi-rigid and it is used to support a weak or deformed body part or for the purpose of restricting or eliminating motion in a diseases or injured body part.  This is a specific requirement under the Medicare Braces Benefit (Social Security Act §1861(s)(9))

A walking boot used solely for treatment of a lower extremity ulcer or pressure reduction must be coded A9283. This is a non-covered benefit under Medicare. It is acceptable to sell the boot as a cash item and accept payment from the patient at time of delivery following these steps:

• Give patient notice of non-coverage of the walking boot for this diagnosis
• Ask the patient to sign an ABN form
• Submit the claim with a GY modifier
• Collect payment from the patient at time of service

What Does This Mean for You?

If you are billing an AFO for prevention or treatment pressure ulcers, it will be denied as a non-covered benefit. If you do not notify the patient prior to claims submission, you will not be able to bill them for the brace once a denial is received.

Update your billing protocols to include A9283 for any AFO used for prevention or treatment of pressure ulcers.

The following HCPCS codes describe an AFO and are covered only when billed for treatment of an injured or deformed body part:

L1902

L1906

L1910

L1930

L1951

L1971

L2035

L2112-2116

L4350

L4360

L4361

L4370

L4386

L4387

L4396-4398