Re: Medicare- Use of Toe Filler with Anterior Panel Carbon Fiber AFO (Responses)
Shelley Blanchard
Description
Collection
Title:
Re: Medicare- Use of Toe Filler with Anterior Panel Carbon Fiber AFO (Responses)
Creator:
Shelley Blanchard
Date:
1/18/2021
Text:
Hello everyone:
Recently one of our CPO's provided a propulsion partial foot prosthesis and
coded L5020, L5976, L5661, L5637, L5640 & L8420 (x6). Medicare denied
L5976 and L5940 as not medically necessary, and does not meet criteria for
the category in which it was billed.
I see these are the same codes listed above as one of the suggestions. I
understand how the L5976 would not be billable with L5020, but no clear
explanation of L5940. I found in in LLP LCD where it states correct
combination of HCPCS codes are billed with L5301 or L5700 with addition of
L5629 or L5940 and with L5321 or L5701 addition of L5331, l5649, & L5950.
Does anyone have any suggestions?
TIA
*Shelley Blanchard, CFm*
*Office Manager*
*Adaptive Prosthetics & Orthotics*
*808 Belanger Street*
*Houma, La 70360*
*985-580-4688*
On Fri, Jan 15, 2021 at 8:38 PM Ashley Seefeld <
<Email Address Redacted> > wrote:
> Hello Listserv!
>
> I wanted to thank everyone who took time to respond to my question. It
> seems that most people were in favor of using the L5020 rather than mixing
> prosthetic and orthotic codes. Several of you requested that I post the
> responses so I've included those below.
>
> *Original post:*
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> *Hello Listserv Community,I have a question that seems like it should have
> been concretely answeredyears ago and yet I cannot find clear guidance
> anywhere (With the exceptionof a discussion from 2013 in the O and P
> Edge).I have a Medicare patient that has recently undergone a TMA. I would
> liketo pair a toe filler with a OTS carbon fiber anterior panel AFO
> (L1932).Research that was published in 2007 during our
> state-of-the-scienceconference shows the clear functional benefits of using
> a tibial tubercleheight partial foot prosthesis (not to mention wound
> prevention). Thisshould be our standard of care at this point as I see
> it.My question is this, How do you code and bill this through Medicare
> sinceL5000 and L1932 are from separate LCDs? The patient has ankle
> equinus,like most TMAs, so I have justification to bill an AFO. Would you
> (*A*)bill them all on one delivery ticket using TMA as the primary
> diagnosis andankle equinus as the secondary diagnosis? Or (*B*) separate
> the claimsonto separate delivery tickets using TMA for the toe filler and
> ankleequinus for the AFO? Or (*C*) do something else that I haven't
> thought of.I really appreciate any links you have to Medicare guidelines on
> this ifyou have found any. *
>
> *Responses:*
>
> No. You keep it simple.
> You bill separate. One for afo and one for PFI. Nothing wrong there.
>
> Bill it as a prosthesis, not as an orthotic. I believe the code is L5020
> but double check me. Bill for carbon acrylic and for custom distal
> padding.
>
> The code for a tibial tubercle height partial foot is L5020. I would use
> that if that is what they are needing. Just make sure your documentation
> explains how it all works together.
>
> You want to bill the L5020 partial foot tibial tubercle height with toe
> filler.
>
> Hi Ashley,
> I have attached the recommended coding for using an AFO as part of a
> partial foot prosthesis. You do not bill the L1932 AFO code since you are
> converting it into a partial foot socket that goes above the ankle you only
> use the prosthetic socket codes. I hope this helps, please do not hesitate
> to reach out if you have any additional questions. The fees are from 2019
> so they are outdated, sorry about that but the coding is what we still use.
> Kind Regards,
> Justi Appel, CO, BOCP, PhD, FAAOP
> Director of Education and Clinical Support
> Allard USA, Inc.
> Preview attachment Allard Partial Foot Coding Supplement.pdf
> Allard Partial Foot Coding Supplement.pdf
> 494 KB
> <
> <URL Redacted>
> >
>
> I would go after the AFO and just add a simple toe filler to it. That would
> be better than billing for a toe filler and getting the AFO denied.
> Funny bc I literally ran in to this yesterday. I would bill Both codes on
> one ticket. And put both diagnoses on the claim. Reference ankle equines
> afo and reference amputation for toe filler. It should
> Not matter which is listed as primary or secondary. What matters is which
> diagnosis is paired with which code. Let me know if you have questions.
>
> Just Bill L5020, which is a above ankle partial foot prosthesis. It is the
> most accurate coding.
>
> You bring up a good question. I don’t really have an answer for you aside
> from option C. For all of my TMAs I do custom partial feet prosthesis, in
> other words, a custom prepreg orthosis built around a partial foot toe
> filler. It keeps all your codes in the prosthetic family, will last much
> long than the OTS carbon brace which are prone to breaking, will
> accommodate varus/valgus /equinus much better, and you can still bill the
> L5000 down the line when the toe filler wears out.
> The codes would be L5020, L5976, L5661, L5637, L5940
> *Add L8420 x(6) for multi-ply prosthetic socks
>
> Bill with L5020 as the listserv indicated. You will need to fab it as one
> unit not an insert and an AFO.
>
> I like the thought and am very familiar with the approach. I would just
> remind you that to have the AFOs approved, don’t forget the weakness or
> deformity of the ankle in the physician chart notes to have the AFO
> approved. Medicare does not consider the amputation as an adequate reason
> for the AFO.
>
> Reach out to Allard as they have addressed this. Making a 'socket' like a
> UCB or SMO with correct calcaneal angle and fixing it to a Toe Off is
> billed as a tibial tubercle height partial foot prosthesis (L5020?). I
> have used several successfully as well as having carbon anterior panel AFOs
> custom made by other central fabs. It is about restoring length of foot
> and correcting a-propulsive gait as well as protecting distal end from
> shear.
>
> Thank you all again!
>
> Ashley Seefeld, CPO
>
> Berke Prosthetics and Orthotics
> 2001 Winward Way, Suite 100
> San Mateo, CA 94404
> P: (650)-570-5861
> F: (650)-365-5896
>
>
Recently one of our CPO's provided a propulsion partial foot prosthesis and
coded L5020, L5976, L5661, L5637, L5640 & L8420 (x6). Medicare denied
L5976 and L5940 as not medically necessary, and does not meet criteria for
the category in which it was billed.
I see these are the same codes listed above as one of the suggestions. I
understand how the L5976 would not be billable with L5020, but no clear
explanation of L5940. I found in in LLP LCD where it states correct
combination of HCPCS codes are billed with L5301 or L5700 with addition of
L5629 or L5940 and with L5321 or L5701 addition of L5331, l5649, & L5950.
Does anyone have any suggestions?
TIA
*Shelley Blanchard, CFm*
*Office Manager*
*Adaptive Prosthetics & Orthotics*
*808 Belanger Street*
*Houma, La 70360*
*985-580-4688*
On Fri, Jan 15, 2021 at 8:38 PM Ashley Seefeld <
<Email Address Redacted> > wrote:
> Hello Listserv!
>
> I wanted to thank everyone who took time to respond to my question. It
> seems that most people were in favor of using the L5020 rather than mixing
> prosthetic and orthotic codes. Several of you requested that I post the
> responses so I've included those below.
>
> *Original post:*
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
> *Hello Listserv Community,I have a question that seems like it should have
> been concretely answeredyears ago and yet I cannot find clear guidance
> anywhere (With the exceptionof a discussion from 2013 in the O and P
> Edge).I have a Medicare patient that has recently undergone a TMA. I would
> liketo pair a toe filler with a OTS carbon fiber anterior panel AFO
> (L1932).Research that was published in 2007 during our
> state-of-the-scienceconference shows the clear functional benefits of using
> a tibial tubercleheight partial foot prosthesis (not to mention wound
> prevention). Thisshould be our standard of care at this point as I see
> it.My question is this, How do you code and bill this through Medicare
> sinceL5000 and L1932 are from separate LCDs? The patient has ankle
> equinus,like most TMAs, so I have justification to bill an AFO. Would you
> (*A*)bill them all on one delivery ticket using TMA as the primary
> diagnosis andankle equinus as the secondary diagnosis? Or (*B*) separate
> the claimsonto separate delivery tickets using TMA for the toe filler and
> ankleequinus for the AFO? Or (*C*) do something else that I haven't
> thought of.I really appreciate any links you have to Medicare guidelines on
> this ifyou have found any. *
>
> *Responses:*
>
> No. You keep it simple.
> You bill separate. One for afo and one for PFI. Nothing wrong there.
>
> Bill it as a prosthesis, not as an orthotic. I believe the code is L5020
> but double check me. Bill for carbon acrylic and for custom distal
> padding.
>
> The code for a tibial tubercle height partial foot is L5020. I would use
> that if that is what they are needing. Just make sure your documentation
> explains how it all works together.
>
> You want to bill the L5020 partial foot tibial tubercle height with toe
> filler.
>
> Hi Ashley,
> I have attached the recommended coding for using an AFO as part of a
> partial foot prosthesis. You do not bill the L1932 AFO code since you are
> converting it into a partial foot socket that goes above the ankle you only
> use the prosthetic socket codes. I hope this helps, please do not hesitate
> to reach out if you have any additional questions. The fees are from 2019
> so they are outdated, sorry about that but the coding is what we still use.
> Kind Regards,
> Justi Appel, CO, BOCP, PhD, FAAOP
> Director of Education and Clinical Support
> Allard USA, Inc.
> Preview attachment Allard Partial Foot Coding Supplement.pdf
> Allard Partial Foot Coding Supplement.pdf
> 494 KB
> <
> <URL Redacted>
> >
>
> I would go after the AFO and just add a simple toe filler to it. That would
> be better than billing for a toe filler and getting the AFO denied.
> Funny bc I literally ran in to this yesterday. I would bill Both codes on
> one ticket. And put both diagnoses on the claim. Reference ankle equines
> afo and reference amputation for toe filler. It should
> Not matter which is listed as primary or secondary. What matters is which
> diagnosis is paired with which code. Let me know if you have questions.
>
> Just Bill L5020, which is a above ankle partial foot prosthesis. It is the
> most accurate coding.
>
> You bring up a good question. I don’t really have an answer for you aside
> from option C. For all of my TMAs I do custom partial feet prosthesis, in
> other words, a custom prepreg orthosis built around a partial foot toe
> filler. It keeps all your codes in the prosthetic family, will last much
> long than the OTS carbon brace which are prone to breaking, will
> accommodate varus/valgus /equinus much better, and you can still bill the
> L5000 down the line when the toe filler wears out.
> The codes would be L5020, L5976, L5661, L5637, L5940
> *Add L8420 x(6) for multi-ply prosthetic socks
>
> Bill with L5020 as the listserv indicated. You will need to fab it as one
> unit not an insert and an AFO.
>
> I like the thought and am very familiar with the approach. I would just
> remind you that to have the AFOs approved, don’t forget the weakness or
> deformity of the ankle in the physician chart notes to have the AFO
> approved. Medicare does not consider the amputation as an adequate reason
> for the AFO.
>
> Reach out to Allard as they have addressed this. Making a 'socket' like a
> UCB or SMO with correct calcaneal angle and fixing it to a Toe Off is
> billed as a tibial tubercle height partial foot prosthesis (L5020?). I
> have used several successfully as well as having carbon anterior panel AFOs
> custom made by other central fabs. It is about restoring length of foot
> and correcting a-propulsive gait as well as protecting distal end from
> shear.
>
> Thank you all again!
>
> Ashley Seefeld, CPO
>
> Berke Prosthetics and Orthotics
> 2001 Winward Way, Suite 100
> San Mateo, CA 94404
> P: (650)-570-5861
> F: (650)-365-5896
>
>
Citation
Shelley Blanchard, “Re: Medicare- Use of Toe Filler with Anterior Panel Carbon Fiber AFO (Responses),” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/255255.
