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Linda Collins Blogger

Custom AFOs Audit Results

Posted by Linda Collins | May 16, 2014

Medicare continues to audit Ankle-Foot Orthoses. Last week Jurisdiction D announced the results of a widespread pre-payment review of HCPCS codes L4360, L1970 and L1960. There was an overall 80% plus denial rate for these claims. The main reasons for denial include:

  • The treating physician’s records did not provide detailed documentation to support medical necessity of a custom orthosis rather than a prefabricated orthosis.
  • Documentation submitted was insufficient to support custom coverage criteria.
  • Documentation submitted was insufficient to support basic coverage criteria
  • There was no detailed written order or dispensing order provided

What does this mean for you?

First, Medicare expects that the beneficiary's medical records will reflect the need for the care provided. This documentation must be available upon request.

In the case of custom-fabricated AFOs, additional documentation is required. The LCD states that for a custom-fabricated orthosis, the patient must meet one of the following criteria, and the medical record must specifically document it:

  • The beneficiary could not be fit with a prefabricated AFO; or
  • The condition necessitating the orthotic 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 beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
  • The beneficiary has a healing fracture that lacks normal anatomic integrity or anthropometric proportions.

This information must be corroborated in the physician’s medical records.

Second, CMS requires you to obtain a detailed written order on all items . The treating physician must sign and date an order for each new or full replacement item billed, the supplier must keep it on file, and it must be made available upon request. A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

  • Beneficiary's name
  • Physician's name
  • Date of the order
  • Detailed description of the item(s)
  • Physician signature and signature date

When a custom fabricated orthosis is ordered, this must be clearly indicated on the DWO.

Put your best foot forward and create a comprehensive DWO and detailed documentation to support the product delivered.

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