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Linda Collins Blogger

New Audit Issue…Watch Your Step

Posted by Linda Collins | March 19, 2013

​The Region A Recovery Auditor has posted a new issue for review. The identified issue is “Ankle-Foot Orthosis.” The specifics of the audit include a review of correct billing codes and supporting medical necessity documentation. This issue is not surprising considering the recent changes in the LCDs and the CERT pre-payment probe.

Currently the issue is only under review in Region A, but we believe it likely that the other three Medicare Regions will pick up the issue for review in the near future.

What can you do to minimize the impact of an audit on AFOs? Follow the product definitions, codes and diagnoses outlined in the LCDs and Policy Articles:

*Ankle-foot orthoses described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory beneficiaries:

  • with weakness or deformity of the foot and ankle,
  • who require stabilization for medical reasons,
  • and have the potential to benefit functionally.

Ossur Products

L1902

GameDay Ankle Brace(PDAC)

L1906*

Rebound Ankle Brace (PDAC)

L1930

AFO Light (PDAC)

L1932

AFO Dynamic (PDAC)

L4350

Air Form Inflatable Stirrup Ankle Brace

L4350

Air Form Stirrup Ankle Brace

 

L4350

Air Form Universal Inflatable Stirrup Ankle Brace

 

L4350

Form Fit Foam Ankle Brace

 

L4350

Form Fit Honeycomb Ankle Brace

 

L4350

Gel Ankle Brace

 

L4360

Equalizer Air Walker (PDAC)

 

L4360

Equalizer Pre-Inflated Air Walker (PDAC)

 

L4360

Malleable Strut Air Walker

 

L4360

Rebound Walker (PDAC)

 

L4386

DH Offloading Walker

 

L4386

Equalizer Walker (inc. low top version)(PDAC)

 

L4386

Pediatric Walker

 

L4386

Range of Motion Walker

 

*Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor.

 Night Splints

*A static or dynamic positioning ankle-foot orthosis (L4396) is a prefabricated ankle-foot orthosis which has all of the following characteristics:

  • Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45°; and,
  • Applies a dorsiflexion force to the ankle; and,
  • Used by a beneficiary who is minimally ambulatory, or nonambulatory; and,
  • Has a soft interface.

 Ossur Products

L4396

Form Fit Night Splint (PDAC)

*A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of the following characteristics:

  • Designed to maintain the foot at a fixed position of 0° and,
  • Not designed to accommodate an ankle with a plantar flexion contracture; and,
  • Used by a beneficiary who is nonambulatory; and,
  • Has a soft interface.

Ossur Products

L4398

Air Form Night Splint (PDAC)

L4398

Exoform Dorsal Night Splint (PDAC)

Modifiers

The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions, and replacement parts.

When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using the RTLT modifiers and 2 units of service.

Add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

Source:
Local Coverage Article for Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article - Effective January 2013 (A19800)

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com