DME MACs Release Updated "Dear Physician" Letter
The DME MACs have updated the "Dear Physician" letter for ankle-foot orthoses and knee-ankle-foot orthoses. In this post, we will review the most important elements of this document.
What You Need to Know
The AFO/KAFO "Dear Physician" letter provides "summary guidance" on Medicare's requirements for these devices. It contains two main sections: (1) "Coverage" - which lays out the basic requirements for an item to qualify as an orthosis (brace) in the first place, and (2) "Medical Necessity Documentation." This post focuses on the latter.
The letter spells out coverage criteria for three different types of AFOs/KAFOs:
- AFOs Not Used During Ambulation are
-Described by either L4396 or L4397;
-Covered if all of the following criteria are met:
*The patient has a non-fixed ankle dorsiflexion contracture of at least 10 degrees as shown by passive range of motion testing; and
*Reasonable expectation that the contracture can be corrected; and
*The contracture does or is expected to significantly interfere with the patient's functional abilities; and
*The AFO is being used as a component of a therapy program that involves active stretching of the involved muscles or tendons.
-Covered if the beneficiary has plantar fasciitis. - AFOs and KAFOs Used During Ambulation
-AFOs are covered for ambulatory patients with weakness or deformity of the foot and ankle who
*Require stabilization for medical reasons, and
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-KAFOs are covered for ambulatory patients for whom an AFO is covered and who require additional knee stability. - Custom-Fabricated AFOs/KAFOs
-Are covered when the basic coverage criteria listed in 2, above, are satisfied, and one of the following criteria are met:
*The patient can't be fit with a prefabricated AFO; or
*The condition necessitating the orthosis is expected to be permanent or lasting longer 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 issue that requires custom fabrication to prevent tissue injury; or
*The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.
What this Means for You
When providing an AFO or KAFO to your patients, you must satisfy the Medical Necessity Documentation requirements listed above. Ideally, your EMR should be set up in a way that any claim for an AFO or KAFO that is missing one or more of these required elements gets flagged for missing documentation so that you can correct any shortcomings.
For the complete AFO/KAFO "Dear Physician" letter, click here.