Medicare resting AFO question: RESPONSES page 1
Randy McFarland
Description
Collection
Title:
Medicare resting AFO question: RESPONSES page 1
Creator:
Randy McFarland
Date:
1/10/2016
Text:
ORIGINAL POST:
Hi Listmembers, I have a patient with a wound at her posterior heel. She
rests in bed in plantarflexion and when PT gets her up to a standing
position the wound gets stretched and opens up when the ankle is
dorsiflexed. She is able to ambulate but is restricted due to her wound
opening up. The patient is on a stretching program. I understand that
resting AFOs generally aren’t covered by Medicare when prescribed just to
relieve for wounds. This orthosis was ordered to position the foot in
plantigrade so the wound can heel in the same angle as when pt is standing
so it won’t get stretched open again when she walks. Have any of you had
success in receiving Medicare reimbursement for a similar situation? I you
are a Medicare claims reviewer, will such a claim be approved or denied?
Thanks, and Happy New Year! Randy McFarland,CPO Fullerton, CA
RESPONSES: Thanks for those who contributed!
The claim will more than likely be denied. Resting AFOs are covered for
ankle instability and not wound care! This is always a tough one for use and
we typically recommend a solid AFO to limit ankle motion while allowing for
stability during standing and walking.
A static/dynamic Ankle-Foot Orthosis (AFO) (L4396, L4397) and replacement
interface (L4392) are denied as noncovered (no Medicare benefit) when they
are used solely for the prevention or treatment of a heel pressure ulcer
because for these indications they are not used to support a weak or
deformed body member or to restrict or eliminate motion in a diseased or
injured part of the body (i.e., it does not meet the definition of a
brace).Certain products may have both covered and non-covered uses, as
defined by the Braces benefit category, and must be coded based on the
beneficiary's condition. For example, when used as a brace for the treatment
of an orthopedic condition, walking boots are coded L4360 and L4386.
However, walking boots must be coded A9283 when used solely for the
prevention or treatment of a lower extremity ulcer or pressure reduction.
Code A9283 (foot pressure off-loading/supportive device) is used for an item
that is designed primarily to reduce pressure on the sole or heel of the
foot. A foot pressure off-loading/supportive device (A9283) is denied as
noncovered (no Medicare benefit), because it does not support a weak or
deformed body member or restrict or eliminate motion in a diseased or
injured part of the body.
Every time I read through one of these policies, I learn something new. The
last time, I remember this section (screenshot below). I hadn’t realized
Medicare covered static AFOs. I just realized a few months ago when seeing
this section that they ARE covered if you meet this criteria. I created an
OPIE alert and emailed my staff. My advice would be to have the PT working
with this lady address each of these criterion in her notes & I further
suggest using Medicare’s own verbiage. For example, have the PT write
“There is a reasonable expectation of the ability to correct this
contracture. The contracture is interfering with the patient’s functional
abilities.” Etcetera, etcetera for each one.
Yes...patient MUST have diagnosis of plantar flexion contracture AND be
ambulatory or potential to ambulate.
Below is the LCD policy concerning static and dynamic positioning. You must
determine if you are meeting all the criteria for payment and it must be
documented. If the patient is in a skilled nursing facility they would need
to provide you with a purchase order.
CMS National Coverage Policy
Coverage Indications Limitations and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the functioning of a
malformed body member, and 3) meet all other applicable Medicare statutory
and regulatory requirements. For the items addressed in this local coverage
determination, the criteria for reasonable and necessary, based on Social
Security Act §1862(a)(1)(A) provisions, are defined by the following
indications and limitations of coverage and/or medical necessity. For an
item to be covered by Medicare, a detailed written order (DWO) must be
received by the supplier before a claim is submitted. If the supplier bills
for an item addressed in this policy without first receiving the completed
DWO, the item will be denied as not reasonable and necessary. AFOs NOT USED
DURING AMBULATION: An L4396 (Static or dynamic positioning ankle-foot
orthosis) is covered if either all of criteria 1 – 4 or criterion 5 is met:
1. Plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47)
with dorsiflexion on passive range of motion testing of at least 10 degrees
(i.e., a non-fixed contracture); and, 2. Reasonable expectation of the
ability to correct the contracture; and, 3. Contracture is interfering or
expected to interfere significantly with the beneficiary's functional
abilities; and, 4. Used as a component of a therapy program which includes
active stretching of the involved muscles and/or tendons. 5. The beneficiary
has plantar fasciitis (ICD-9 diagnosis code 728.71). If an L4396 is used for
the treatment of a plantar flexion contracture, the pre-treatment passive
range of motion must be measured with a goniometer and documented in the
medical record. There must be documentation of an appropriate stretching
program carried out by professional staff (in a nursing facility) or
caregiver (at home). An L4396 and replacement interface (L4392) will be
denied as not reasonable and necessary if the contracture is fixed. Codes
L4396 and L4392 will be denied as not reasonable and necessary for a patient
with a foot drop but without an ankle flexion contracture. A component of a
static/dynamic AFO that is used to address positioning of the knee or hip
will be denied as not reasonable and necessary because the effectiveness of
this type of component is not established. If code L4396 is covered, a
replacement interface (L4392) is covered as long as the patient continues to
meet indications and other coverage rules for the splint. Coverage of a
replacement interface is limited to a maximum of one (1) per 6 months.
Additional interfaces will be denied as not reasonable and necessary.
Medicare does not reimburse for a foot drop splint/recumbent positioning
device (L4398) or replacement interface (L4394). A foot drop
splint/recumbent positioning device and replacement interface will be denied
as not reasonable and necessary in a patient with foot drop who is
non-ambulatory because there are other more appropriate treatment
modalities. Hope this clears it up for you.
I don't think you have a chance of getting water in a drought year; i.e. any
payment for what you describe. Sounds like you already have SNF or long
term care issues to boot for this patient.
build for the deformity not the condition
I believe resting AFO's (Mutipodus AFO's) are covered by Medicare as long as
a Dx of Plantar flexion contracture or Plantar fasciitis can be documented.
Hi Listmembers, I have a patient with a wound at her posterior heel. She
rests in bed in plantarflexion and when PT gets her up to a standing
position the wound gets stretched and opens up when the ankle is
dorsiflexed. She is able to ambulate but is restricted due to her wound
opening up. The patient is on a stretching program. I understand that
resting AFOs generally aren’t covered by Medicare when prescribed just to
relieve for wounds. This orthosis was ordered to position the foot in
plantigrade so the wound can heel in the same angle as when pt is standing
so it won’t get stretched open again when she walks. Have any of you had
success in receiving Medicare reimbursement for a similar situation? I you
are a Medicare claims reviewer, will such a claim be approved or denied?
Thanks, and Happy New Year! Randy McFarland,CPO Fullerton, CA
RESPONSES: Thanks for those who contributed!
The claim will more than likely be denied. Resting AFOs are covered for
ankle instability and not wound care! This is always a tough one for use and
we typically recommend a solid AFO to limit ankle motion while allowing for
stability during standing and walking.
A static/dynamic Ankle-Foot Orthosis (AFO) (L4396, L4397) and replacement
interface (L4392) are denied as noncovered (no Medicare benefit) when they
are used solely for the prevention or treatment of a heel pressure ulcer
because for these indications they are not used to support a weak or
deformed body member or to restrict or eliminate motion in a diseased or
injured part of the body (i.e., it does not meet the definition of a
brace).Certain products may have both covered and non-covered uses, as
defined by the Braces benefit category, and must be coded based on the
beneficiary's condition. For example, when used as a brace for the treatment
of an orthopedic condition, walking boots are coded L4360 and L4386.
However, walking boots must be coded A9283 when used solely for the
prevention or treatment of a lower extremity ulcer or pressure reduction.
Code A9283 (foot pressure off-loading/supportive device) is used for an item
that is designed primarily to reduce pressure on the sole or heel of the
foot. A foot pressure off-loading/supportive device (A9283) is denied as
noncovered (no Medicare benefit), because it does not support a weak or
deformed body member or restrict or eliminate motion in a diseased or
injured part of the body.
Every time I read through one of these policies, I learn something new. The
last time, I remember this section (screenshot below). I hadn’t realized
Medicare covered static AFOs. I just realized a few months ago when seeing
this section that they ARE covered if you meet this criteria. I created an
OPIE alert and emailed my staff. My advice would be to have the PT working
with this lady address each of these criterion in her notes & I further
suggest using Medicare’s own verbiage. For example, have the PT write
“There is a reasonable expectation of the ability to correct this
contracture. The contracture is interfering with the patient’s functional
abilities.” Etcetera, etcetera for each one.
Yes...patient MUST have diagnosis of plantar flexion contracture AND be
ambulatory or potential to ambulate.
Below is the LCD policy concerning static and dynamic positioning. You must
determine if you are meeting all the criteria for payment and it must be
documented. If the patient is in a skilled nursing facility they would need
to provide you with a purchase order.
CMS National Coverage Policy
Coverage Indications Limitations and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the functioning of a
malformed body member, and 3) meet all other applicable Medicare statutory
and regulatory requirements. For the items addressed in this local coverage
determination, the criteria for reasonable and necessary, based on Social
Security Act §1862(a)(1)(A) provisions, are defined by the following
indications and limitations of coverage and/or medical necessity. For an
item to be covered by Medicare, a detailed written order (DWO) must be
received by the supplier before a claim is submitted. If the supplier bills
for an item addressed in this policy without first receiving the completed
DWO, the item will be denied as not reasonable and necessary. AFOs NOT USED
DURING AMBULATION: An L4396 (Static or dynamic positioning ankle-foot
orthosis) is covered if either all of criteria 1 – 4 or criterion 5 is met:
1. Plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47)
with dorsiflexion on passive range of motion testing of at least 10 degrees
(i.e., a non-fixed contracture); and, 2. Reasonable expectation of the
ability to correct the contracture; and, 3. Contracture is interfering or
expected to interfere significantly with the beneficiary's functional
abilities; and, 4. Used as a component of a therapy program which includes
active stretching of the involved muscles and/or tendons. 5. The beneficiary
has plantar fasciitis (ICD-9 diagnosis code 728.71). If an L4396 is used for
the treatment of a plantar flexion contracture, the pre-treatment passive
range of motion must be measured with a goniometer and documented in the
medical record. There must be documentation of an appropriate stretching
program carried out by professional staff (in a nursing facility) or
caregiver (at home). An L4396 and replacement interface (L4392) will be
denied as not reasonable and necessary if the contracture is fixed. Codes
L4396 and L4392 will be denied as not reasonable and necessary for a patient
with a foot drop but without an ankle flexion contracture. A component of a
static/dynamic AFO that is used to address positioning of the knee or hip
will be denied as not reasonable and necessary because the effectiveness of
this type of component is not established. If code L4396 is covered, a
replacement interface (L4392) is covered as long as the patient continues to
meet indications and other coverage rules for the splint. Coverage of a
replacement interface is limited to a maximum of one (1) per 6 months.
Additional interfaces will be denied as not reasonable and necessary.
Medicare does not reimburse for a foot drop splint/recumbent positioning
device (L4398) or replacement interface (L4394). A foot drop
splint/recumbent positioning device and replacement interface will be denied
as not reasonable and necessary in a patient with foot drop who is
non-ambulatory because there are other more appropriate treatment
modalities. Hope this clears it up for you.
I don't think you have a chance of getting water in a drought year; i.e. any
payment for what you describe. Sounds like you already have SNF or long
term care issues to boot for this patient.
build for the deformity not the condition
I believe resting AFO's (Mutipodus AFO's) are covered by Medicare as long as
a Dx of Plantar flexion contracture or Plantar fasciitis can be documented.
Citation
Randy McFarland, “Medicare resting AFO question: RESPONSES page 1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/237956.
