Responses to neurpoathic/diabetic foot orthosis
Christopher Hovorka
Description
Collection
Title:
Responses to neurpoathic/diabetic foot orthosis
Creator:
Christopher Hovorka
Date:
10/6/1999
Text:
Dear fellow listservers:
Thank you all for your responses to my questions. Following this overview are the responses to the questions I posted regarding foot orthosis treatment and billing for neuropathic and diabetic foot patients. The theme to many of these responses is that the A-codes, not the L-codes should be used when providing custom foot orthoses for diabetic patients and that a customized, not prefabricated orthosis should be utilized (due to the compromising nature of neuropathy and skin pressure tolerance particularly when protective sensation is absent). Most responses for customized orthoses involve a multidurometer device made of various soft accommodative foams as a top layer and more dense materials as a base layer. Several respondents suggest the use of extra depth shoes in addition to a custom foot orthosis. In addition, some respondents stressed the importance of differentiating whether a neuropathic lesion was present of not and if one was present that possibly more than just a foot orthosis (i.e. AFO) would be indicated for off-loading the lesion. Some respondents suggested that non-customized treatments involve Otto Bock prefab foot orthosis and depth shoes such as Apex Ambulators. Also, I provided an additional bit of information from another related question posted by a colleague. The two posts are listed at the end of this document.
First, the orignal questions were as follows:
> I have questions for the group on the use of foot orthoses for persons with neuropathy, particularly of diabetic origin:
> 1.) Is there a non-customized type of foot orthosis made of an accommodative yet relatively durable material available for these persons.
> 2.) Also, what HCFA L-codes are being used for this?
> Chris Hovorka, MS, CPO
> University of Texas Southwestern
> Medical Center at Dallas
> Prosthetics-Orthotics Program
__________________________________
Apex makes the ambulator shoe design. These shoes can include the optional diabetic insert. It has a top layer of plastazote and also has
a gel layer. My patients tell me it is very comfortable.
I don't remember the codes, but they are not L codes, they are A codes. I don't have the specific code here.
email me back with a phone # if you need the code.
__________________________________
At our Diabetes foot Clinics the non-custom foot bed of choice is 1/4 P1 plastazote over 1/4 PPT.
____________________________________________Contact Joe Bash at Otto Bock. He can help. 1-800-344-4233
__________________________________
I think the newer design of the Apex Ambulator shoes have the best insert
I've seen. To my knowledge - you cannot bill separately for a non-custom
insert. The shoes are inexpensive enough and you can bill for the shoes.
I really recommend for my arthritics and non-diabetics who cannot afford
to pay and who don't have funding for shoes and inserts.
__________________________________
Subject of foot orthotics. I'm still providing custom ones for by diabetics.
We usually make them in-house of a tri-lam material. They've been working
pretty well.
_________________________________
Otto Bock makes a pretty nice pre-fab plastizote / bocklite insert ,
Call Joe Bash -- as far as billing for Medicare -- the L code is an A-code
A5502 and Medicare reimbursement in our neck of the woods is about $31.18.
____________________________________________
Refer to following L-codes used in diabetic patients which includes
xtra depth shoe or similar.
A5500, A5503, A5504, A5505, A5506, A5501, A5502
____________________________________________
I read your question regarding a non-custom foot orthosis for neuropathy as associated with diabetic patients. If your need is for an AFO for management of drop foot, have you seen a product called ToeOFF? This is a carbon composite (fiberglass, carbon fiber, and Kevlar) dynamic response AFO that uses a lateral strut and anterior tibial plate for support. There is no heel cup, eliminating any pressure on the calcaneus or calf. I am attaching a picture. SADMERC suggested coding is L1945 + L2755. ToeOFF is like a shell -- it is necessary that the orthotist add appropriate heel lift, channel padding for the tibia, posting, etc. to assure as normal gait as possible. ToeOFF is offered in 4 sizes, left and right. For more information, please contact CAMP at 800 492 1088. Be sure to ask for their brochure, article by Dr. Willner, PLUS their wall poster customization guide.
___________________________________________
a large percentage of our patients are diabetics with varying degrees of neuropathic foot problems.
In most cases, we try to treat these patients, depending on their risk
category, with a combination of extra depth shoes (Apex Ambulators) and
custom foot orthoses (usually consisting of a trilaminar cushioning and
crepe or thermocork).
However, there are a number of companies that make a fairly decent prefab
inlays--Apex and Acor come to mind. Acor makes a line of supports called
Quikform, that you can heat mold, overall or in spots. It is a trilaminar
inlay.
We are using L3002 or A5502(Medicare Diabetic Shoe Bill). If the patient
is truly neuropathic, usually based on monofilament testing, then we always
provide a custom-molded accomodative foot orthosis. We normally use 1/8
plastazote, 1/8 poron or ppt, and puff/cork to fabricate the orthoses.
They normally last 4-6 months depending on several factors. So, follow-up
with these patients is important. This can often be difficult with this
patient population. A few companies (ACOR) do make premolded blanks that
you can customize. We have not yet tried this system. In the end, the
reimbursement normally does not cover the time, labor, and material costs.
But, we do what we have to do. Good Luck.
____________________________________________
I AM THE DIRECTOR OF SALES OF ANATOMICAL CONCEPTS, INC. YOU WERE ASKING FOR A NONCUSTOMIZED AFO FOR PATIENTS, PLEASE CHECK OUT OUR WEBSITE AT PRAFO.COM. I WILL FORWARD BY WAY OF FAX THE DMERC'S RECOMMENDATION IN WAY OF L-CODES. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT ME AT 800-837-3888. I HOPE THIS IS HELPFUL FOR YOU.
____________________________________________
First off, let me ask you if you are trying to offload a neuropathic
ulcer? If that is the case, either a total Contact type Polymer AFO
is indicated, or, in lieu of that, you can use a SAWO with a 1/2
Plastazote insert. Now, if you are just trying to find a AFO that is
good for neuropathy, I use a Double upright configuration, with
accomodative inserts made of Cork and Tri Laminate. I do not like
using a polymer AFO for an insensate foot.
Unfortunately, a number of Diabetics also succumb to
developing a Charcot foot. Then, an Axial resist AFO is
indicated.
The L codes we use for the SAWO is L4360, the Total Contact
AFO would be coded as a Solid Ankle AFO with Anterior shell.
Sorry that I do not have those codes available.
____________________________________________
I am sincere when I ask you to proceed
with caution when describing foot orthotics for diabetes as non-molded or
non custom when billing to Medicare: they expect all diabetes orthotics to be
custom. If you use L-codes to bill to Medicare for these, the claim will be
denied. Correct Codes are A-5000 series codes that allow billing as eaches
for off shelf diabetic shoes, multidensity inserts, custom molded shoes and
modifications to shoes or inserts. The only allowable L-code is the one for
toe filler insert, of which, I do not recall the exact code but it is the
front of all the prosthetic codes.
Since you are a staffer at UT, it occurs to me that this post is a cloaked
attempt to se if any orthotists are goofy enough to think they are getting
L-codes paid for this work. If you do find this out, please act in discretion
in helping our associates get their coding policies up to speed. I wish you
all success at UT.
____________________________________________
Apex makes the ambulator shoe design. These shoes can include the optional diabetic insert. It has a top layer of plastazote and also has
a gel layer. My patients tell me it is very comfortable.
I don't remember the codes, but they are not L codes, they are A codes. I don't have the specific code here.
email me back with a phone # if you need the code.
____________________________________________
What level of service do you provide for this L-code? This code isn't meant to be custom is it? Is there a way in the A codes to provide a custom insert, ie Biofoam impression, vacuum form plastizote, pelite, etc. over a positive mold for a diabetic patient?
A5502 For Diabetics Only, Multi Density Insert(s), Per Shoe $32.00
Also is it totally improper to bill out L3010 or L3020 for a diabetic patient to Medicare?
____________________________________________
Good questions! It is my understanding that you can only use A codes for
diabetic patients requiring therapeutic footwear. The Medicare Carrier's
manual will define each code and give explanations of each. I believe any
L codes will be denied as non-covered.
Our DMERC has established the following guidelines;
Each calendar year, a patient meeting the eligibility requirements is
entitled to either a pair of A5501 and 2 pairs of A5502 OR a pair of A5500
and 3 pairs of A5502. There are other requirements to be aware of, i.e.,
Certification Statement, etc. that you must comply with.
The policy is only four pages long but I'm not sure of any updates that would
apply. I'd be happy to fax it to you if you need it. Another resource would
be Kathy Dodson at AOPA. She should be up-to-snuff with the requirements.
********************
OANDP-L is a forum for the discussion of topics related to Orthotics and
Prosthetics.
Public commercial postings are forbidden. Responses to inquiries of a
commercial nature should not be sent to the entire oandp-l list. Responses
should be collected and reposted by the person asking the question.
Send a message to the list by sending to: <Email Address Redacted> To unsubscribe,
send a message to: <Email Address Redacted> with the words UNSUB OANDP-L in the body of the
message. All postings related to US-politics must use a subject line
starting with US-Politics:
Any questions should be directed to Paul E. Prusakowski, CPO at
<Email Address Redacted>
Thank you all for your responses to my questions. Following this overview are the responses to the questions I posted regarding foot orthosis treatment and billing for neuropathic and diabetic foot patients. The theme to many of these responses is that the A-codes, not the L-codes should be used when providing custom foot orthoses for diabetic patients and that a customized, not prefabricated orthosis should be utilized (due to the compromising nature of neuropathy and skin pressure tolerance particularly when protective sensation is absent). Most responses for customized orthoses involve a multidurometer device made of various soft accommodative foams as a top layer and more dense materials as a base layer. Several respondents suggest the use of extra depth shoes in addition to a custom foot orthosis. In addition, some respondents stressed the importance of differentiating whether a neuropathic lesion was present of not and if one was present that possibly more than just a foot orthosis (i.e. AFO) would be indicated for off-loading the lesion. Some respondents suggested that non-customized treatments involve Otto Bock prefab foot orthosis and depth shoes such as Apex Ambulators. Also, I provided an additional bit of information from another related question posted by a colleague. The two posts are listed at the end of this document.
First, the orignal questions were as follows:
> I have questions for the group on the use of foot orthoses for persons with neuropathy, particularly of diabetic origin:
> 1.) Is there a non-customized type of foot orthosis made of an accommodative yet relatively durable material available for these persons.
> 2.) Also, what HCFA L-codes are being used for this?
> Chris Hovorka, MS, CPO
> University of Texas Southwestern
> Medical Center at Dallas
> Prosthetics-Orthotics Program
__________________________________
Apex makes the ambulator shoe design. These shoes can include the optional diabetic insert. It has a top layer of plastazote and also has
a gel layer. My patients tell me it is very comfortable.
I don't remember the codes, but they are not L codes, they are A codes. I don't have the specific code here.
email me back with a phone # if you need the code.
__________________________________
At our Diabetes foot Clinics the non-custom foot bed of choice is 1/4 P1 plastazote over 1/4 PPT.
____________________________________________Contact Joe Bash at Otto Bock. He can help. 1-800-344-4233
__________________________________
I think the newer design of the Apex Ambulator shoes have the best insert
I've seen. To my knowledge - you cannot bill separately for a non-custom
insert. The shoes are inexpensive enough and you can bill for the shoes.
I really recommend for my arthritics and non-diabetics who cannot afford
to pay and who don't have funding for shoes and inserts.
__________________________________
Subject of foot orthotics. I'm still providing custom ones for by diabetics.
We usually make them in-house of a tri-lam material. They've been working
pretty well.
_________________________________
Otto Bock makes a pretty nice pre-fab plastizote / bocklite insert ,
Call Joe Bash -- as far as billing for Medicare -- the L code is an A-code
A5502 and Medicare reimbursement in our neck of the woods is about $31.18.
____________________________________________
Refer to following L-codes used in diabetic patients which includes
xtra depth shoe or similar.
A5500, A5503, A5504, A5505, A5506, A5501, A5502
____________________________________________
I read your question regarding a non-custom foot orthosis for neuropathy as associated with diabetic patients. If your need is for an AFO for management of drop foot, have you seen a product called ToeOFF? This is a carbon composite (fiberglass, carbon fiber, and Kevlar) dynamic response AFO that uses a lateral strut and anterior tibial plate for support. There is no heel cup, eliminating any pressure on the calcaneus or calf. I am attaching a picture. SADMERC suggested coding is L1945 + L2755. ToeOFF is like a shell -- it is necessary that the orthotist add appropriate heel lift, channel padding for the tibia, posting, etc. to assure as normal gait as possible. ToeOFF is offered in 4 sizes, left and right. For more information, please contact CAMP at 800 492 1088. Be sure to ask for their brochure, article by Dr. Willner, PLUS their wall poster customization guide.
___________________________________________
a large percentage of our patients are diabetics with varying degrees of neuropathic foot problems.
In most cases, we try to treat these patients, depending on their risk
category, with a combination of extra depth shoes (Apex Ambulators) and
custom foot orthoses (usually consisting of a trilaminar cushioning and
crepe or thermocork).
However, there are a number of companies that make a fairly decent prefab
inlays--Apex and Acor come to mind. Acor makes a line of supports called
Quikform, that you can heat mold, overall or in spots. It is a trilaminar
inlay.
We are using L3002 or A5502(Medicare Diabetic Shoe Bill). If the patient
is truly neuropathic, usually based on monofilament testing, then we always
provide a custom-molded accomodative foot orthosis. We normally use 1/8
plastazote, 1/8 poron or ppt, and puff/cork to fabricate the orthoses.
They normally last 4-6 months depending on several factors. So, follow-up
with these patients is important. This can often be difficult with this
patient population. A few companies (ACOR) do make premolded blanks that
you can customize. We have not yet tried this system. In the end, the
reimbursement normally does not cover the time, labor, and material costs.
But, we do what we have to do. Good Luck.
____________________________________________
I AM THE DIRECTOR OF SALES OF ANATOMICAL CONCEPTS, INC. YOU WERE ASKING FOR A NONCUSTOMIZED AFO FOR PATIENTS, PLEASE CHECK OUT OUR WEBSITE AT PRAFO.COM. I WILL FORWARD BY WAY OF FAX THE DMERC'S RECOMMENDATION IN WAY OF L-CODES. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT ME AT 800-837-3888. I HOPE THIS IS HELPFUL FOR YOU.
____________________________________________
First off, let me ask you if you are trying to offload a neuropathic
ulcer? If that is the case, either a total Contact type Polymer AFO
is indicated, or, in lieu of that, you can use a SAWO with a 1/2
Plastazote insert. Now, if you are just trying to find a AFO that is
good for neuropathy, I use a Double upright configuration, with
accomodative inserts made of Cork and Tri Laminate. I do not like
using a polymer AFO for an insensate foot.
Unfortunately, a number of Diabetics also succumb to
developing a Charcot foot. Then, an Axial resist AFO is
indicated.
The L codes we use for the SAWO is L4360, the Total Contact
AFO would be coded as a Solid Ankle AFO with Anterior shell.
Sorry that I do not have those codes available.
____________________________________________
I am sincere when I ask you to proceed
with caution when describing foot orthotics for diabetes as non-molded or
non custom when billing to Medicare: they expect all diabetes orthotics to be
custom. If you use L-codes to bill to Medicare for these, the claim will be
denied. Correct Codes are A-5000 series codes that allow billing as eaches
for off shelf diabetic shoes, multidensity inserts, custom molded shoes and
modifications to shoes or inserts. The only allowable L-code is the one for
toe filler insert, of which, I do not recall the exact code but it is the
front of all the prosthetic codes.
Since you are a staffer at UT, it occurs to me that this post is a cloaked
attempt to se if any orthotists are goofy enough to think they are getting
L-codes paid for this work. If you do find this out, please act in discretion
in helping our associates get their coding policies up to speed. I wish you
all success at UT.
____________________________________________
Apex makes the ambulator shoe design. These shoes can include the optional diabetic insert. It has a top layer of plastazote and also has
a gel layer. My patients tell me it is very comfortable.
I don't remember the codes, but they are not L codes, they are A codes. I don't have the specific code here.
email me back with a phone # if you need the code.
____________________________________________
What level of service do you provide for this L-code? This code isn't meant to be custom is it? Is there a way in the A codes to provide a custom insert, ie Biofoam impression, vacuum form plastizote, pelite, etc. over a positive mold for a diabetic patient?
A5502 For Diabetics Only, Multi Density Insert(s), Per Shoe $32.00
Also is it totally improper to bill out L3010 or L3020 for a diabetic patient to Medicare?
____________________________________________
Good questions! It is my understanding that you can only use A codes for
diabetic patients requiring therapeutic footwear. The Medicare Carrier's
manual will define each code and give explanations of each. I believe any
L codes will be denied as non-covered.
Our DMERC has established the following guidelines;
Each calendar year, a patient meeting the eligibility requirements is
entitled to either a pair of A5501 and 2 pairs of A5502 OR a pair of A5500
and 3 pairs of A5502. There are other requirements to be aware of, i.e.,
Certification Statement, etc. that you must comply with.
The policy is only four pages long but I'm not sure of any updates that would
apply. I'd be happy to fax it to you if you need it. Another resource would
be Kathy Dodson at AOPA. She should be up-to-snuff with the requirements.
********************
OANDP-L is a forum for the discussion of topics related to Orthotics and
Prosthetics.
Public commercial postings are forbidden. Responses to inquiries of a
commercial nature should not be sent to the entire oandp-l list. Responses
should be collected and reposted by the person asking the question.
Send a message to the list by sending to: <Email Address Redacted> To unsubscribe,
send a message to: <Email Address Redacted> with the words UNSUB OANDP-L in the body of the
message. All postings related to US-politics must use a subject line
starting with US-Politics:
Any questions should be directed to Paul E. Prusakowski, CPO at
<Email Address Redacted>
Citation
Christopher Hovorka, “Responses to neurpoathic/diabetic foot orthosis,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 26, 2024, https://library.drfop.org/items/show/212973.
