Responses Medicaire AFO/KAFO inquiry

Responses Medicaire AFO/KAFO inquiry

Keith Smith

12/10/2012

Thanks to All for their replies. See below for responses to inquiry.



original post: Wanted to find out if the field has been successful billing for a KAFO within the same 5 year period that an AFO had been been billed without getting a same or similar denial. The AFO would be for dropfoot for instance and now the KAFO for dropfoot and also total knee instability with grade 0 quads. Thanks in advance for all responses,

RESPONSES:


I have done this successfully quite a number of times, and only one denial that I can recall, but I also have not done one like this in a few years, so I don't know how that might work in the new QIC/RAC/ZPIC world.
Most of the folks I did this kind of thing for were MS patients, so progression would be expected. What appeared to be critical were the diagnosis codes used in the two billing events. My own interpretation of how they look at this is that if the provider could have reasonably expected the change requiring the KAFO, then they are more likely to deny it. With MS, for instance, there are widely varying rates of progression, and while you might expect to need a KAFO at some point, for some patients, you have no particular reason to expect it within the five year window. In many cases, by the time many MS patients need a KAFO for their leg (s), they are no longer ambulatory for other reasons. Only a small percentage of my MS patients were ever provided with a KAFO, so that pattern was probably significant. If I had provided KAFOs to every MS patient 2-4 years after providing an AFO, they would have reason to suspect that I was either scamming them or didn't know how to evaluate patients very well.
In two other cases I remember, there was a drop foot present from spinal stenosis, and then later there were complications of TKAs done on the same side. Those diagnoses are not in any way interconnected, and Medicare could also see that a knee surgery had been performed, so there would not likely be a denial. These can get complicated when part of the patient's relevant conditions were in play prior to going on Medicare, so they don't have a history to inform them. You could expect at least a pre-payment review under those circumstances.
Another issue is the timing. Changing to a KAFO after four years looks very different than changing after 8 months, and probably should, at least most of the time.

In your case, it would seem unlikely that the knee and ankle conditions are from the same cause, unless it was from two or more spine surgeries that both had neurologic complications. That should help your case, but again, in the brave new world of a financially strapped Medicare, all bets are off. Just because it is within the five year window, you can probably expect a pre-payment review, but assuming that the quads were 3 or better at the time the AFO was provided, you should ultimately be paid, even if it is by an ALJ ruling.

I assume that people do this, but I know that some don't, so please don't be insulted if this doesn't apply to you. With these kinds of cases, meticulous documentation can save your bacon, and in many cases get you your payment at the first review, even under circumstances like these. Lay out in detail a very thorough evaluation, tests of all muscles and ROM in both legs (get the patient back in and re-evaluate, if necessary), the patient's impressions, spouse's impressions/concerns, fall history, gait analysis with the AFO only, anything that is relevant. This is not a bury them in BS approach, but sending the message that you have taken the time to understand the patient's situation, can think in an orderly and comprehensive fashion, and here is why the KAFO is really necessary. With Grade 0 quads, there is obviously a safety issue, and if present, being able to reference your notes from when you provided the AFO, and how different things are now (quad strength, if tested then, gait then, with and without the AFO, etc.), can be huge. I am kind of a documentation geek, and was before the current review mess, but part of why I do that is to improve the chances of getting paid for what we do. Some of the notes I have seen from other providers make me wonder how they ever survive any review.

-----------------------

The medical condition changed and there is supporting documentation in the
doctors records. In our experience the claim was never questioned or
delayed.
------------------------
Properly documented, there should not be a problem. It's a different base code.

------------------
I have billed many times for same device, similar device as soon as a year later. I have done this at least 50 times. I have always been paid! Not one denial or audit. The five year rule has NEVER been enforced. I haven't even had them sign ABNs in over 3 years.

--------------------
shouldn't theoretically be a problem if it is due to a documented change of condition and the fact that they are different levels
-----------------------
shouldn't be a problem since his physical condition has changed and will be evident by two or more diagnoses. Also you can include comment about lack of quad strength
-------------------
Send a paper claim with an LMN included stating a condition change / DX change resulting in additional brace and you should be fine. Change in condition is an exception of 5 yr rule.
-------------------
If the KAFO is now needed, it should be due to a change in the patient's
physical condition so you would need to have physician and maybe PT
documentation indicating the difference. So long as this documentation
exists, the Medicare will cover changes within the devices useful lifetime
--------------------
different lcodes, shouldn't be denied
forgot to include if it serves a different function ie kafo to stabilize knee

-------------------

Thanks again for the replies,

Keith M Smith CO LO FAAOP