LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-03 LCD A19885 Ankle-Foot/Knee-Ankle-Foot Orthosis

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Local Coverage Article for ANKLE-FOOT/Knee-ANKLE-FOOT Orthosis – Policy Article – Effective January 2011 (A19885)

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

  • 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. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary?).
  • For an item to be considered for coverage under the Braces benefit category, it must be a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. It must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used to brace. Items that do not meet the definition of a brace are noncovered.
  • A static/dynamic ANKLE-FOOT Orthosis (AFO) (L4396 or L4397 / L1930) 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). For reasonable and necessary determinations for the use of L4396 and L4392 refer to the Medical Necessity Coverage and Payment Rules under “AFOs Not Used During Ambulation? in the AFO/KAFO Local Coverage Determination.
  • A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) are denied as noncovered (no Medicare benefit) when they are used solely for the prevention or treatment of a 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). For reasonable and necessary determinations for the use of L4398 and L4394 refer to the Medical Necessity Coverage and Payment Rules under “AFOs Not Used During Ambulation? in the AFO/KAFO Local Coverage Determination.
  • 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.
  • Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid must be coded A4466. Code A4466 is denied as noncovered (no Medicare benefit).
  • Socks (L2840, L2850) used in conjunction with orthoses are denied as noncovered (no Medicare benefit).
  • Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are not covered.
  • Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

CODING GUIDELINES

  • Ankle flexion contracture is a condition in which there is shortening of the muscles and/or tendons that plantarflex the ankle with the resulting inability to bring the ankle to 0 degrees by passive range of motion. (0 degrees ankle position is when the foot is perpendicular to the lower leg.)
  • Foot drop is a condition in which there is weakness and/or lack of use of the muscles that dorsiflex the ankle but there is the ability to bring the ankle to 0 degrees by passive range of motion.
  • Plantar fasciitis is an inflammation of the heel of the foot typically resulting from trauma to the deep tissue of the foot (i.e., plantar fascia).
  • A prefabricated orthosis is one which is manufactured in quantity without a specific patient in mind. A prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient (i.e., custom fitted). An orthosis that is assembled from prefabricated components is considered prefabricated. Any orthosis that does not meet the definition of a custom-fabricated orthosis is considered prefabricated.
  • A custom-fabricated orthosis is one which is individually made for a specific patient starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as cutting, bending, molding, sewing, etc. It may involve the incorporation of some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item.
  • ANKLE-FOOT orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthotics which are shoe inserts that do not extend above the ankle.
  • A nonambulatory ANKLE-FOOT orthosis may be either an ankle contracture splint, night splint or a foot drop splint.
  • 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 patient who is minimally ambulatory, or nonambulatory; and Has a soft interface.
  • 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° (i.e., perpendicular to the lower leg); and Not designed to accommodate an ankle with a plantar flexion contracture; and Used by a patient who is nonambulatory; and Has a soft interface.
  • Code L4631 describes a Charcot’s restraint orthotic walker (CROW) orthosis. Code L4631 is a custom fabricated ANKLE-FOOT orthosis which has all of the following characteristics: Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and, Allows for varus or valgus deformity correction; and, Contains a rocker bottom sole with a custom arch support; and,
    Incorporates a rigid anterior tibial shell; and, Used by a patient who is ambulatory; and, Has a soft interface. Code L4631 includes all additions including straps and closures. No additional codes may be billed with code L4631.
  • Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2030, L2034, L2036-L2108, L2126-L2128 and L4631 describe custom-fabricated orthoses. These codes must not be used for prefabricated (i.e., non-custom-fabricated) orthoses.
  • Codes L1902, L1906, L1910, L1930, L1951, L1971, L2035, L2112-L2116, and L2132-L2136 describe prefabricated orthoses. These codes must not be used for custom-fabricated orthoses.
  • Codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are used for an ANKLE-FOOT orthosis which is worn when a patient is ambulatory. Code L4396 is used for an ANKLE-FOOT orthosis which is worn when a patient is nonambulatory, or minimally ambulatory. Code L4398 is used for an ANKLE-FOOT orthosis which is worn when a patient is nonambulatory.
  • Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. For example, replacement soft interfaces used with ankle contracture orthoses or foot drop splints are billed with codes L4392 and L4394, respectively. Replacement components that do not have a unique HCPCS code must be billed with a “not otherwise specified” code – L2999. HCPCS codes L4050-L4055 do not describe replacement soft interfaces used with contracture orthoses.
  • Code L4205 is used for the labor component of repair of a previously provided orthosis except for any labor involved in the replacement of an orthotic component that has a specific L code. It may only be billed for the actual time involved in the repair of an orthosis. It must not be used for any labor involved in the evaluation, fabrication, or fitting of a new or full replacement orthosis. Labor involved in the replacement of an orthotic component that has a specific L code is not separately billable.
  • ANKLE-FOOT orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. Foot orthotics are shoe inserts that do not extend above the ankle. The correct codes for foot orthotics provided for patients without diabetes are L3000-L3090 (Refer to the Orthopedic Footwear policy for more information). Multiple density foot orthotics used in the management of diabetic foot problems are coded A5512 and A5513 (Refer to the Therapeutic Shoes for Persons with Diabetes policy for more information).
  • Claims for prefabricated or custom-fabricated devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint should be coded as E1810 (dynamic adjustable knee extension/flexion device, includes soft interface material) or E1815 (dynamic adjustable ankle extension/flexion device, includes soft interface material), respectively. All lines on claims billed with L-codes (i.e., L2861) for devices incorporating a concentric adjustable torsion style mechanism in the knee or ankle joint will be rejected as incorrect coding.
  • 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. It may be a shoe-like item, an item that is used inside a shoe and may or may not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated. Code A9283 does not include items that meet the definition of a therapeutic shoe for diabetes (A5500, A5501).
  • Certain products may have both covered and non-covered uses, as defined by the Braces benefit category, and must be coded based on the patient’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.
  • When using code A9283, there is no separate billing using addition codes. Replacement liners for devices billed with A9283 must be billed with code A9270 (noncovered item or service).
  • 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. Claims billed without modifiers RT and/or LT will be rejected as incorrect coding.
  • Evaluation of the patient, measurement and/or casting, and fitting of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.
  • Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier’s record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.
  • The allowance for the labor involved in replacing an orthotic component that is coded with a specific L code is included in the allowance for that component. The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous code L4210 is separately payable in addition to the allowance for that component.
  • Addition codes L4002 – L4130, and L4392 are for billing of replacement components and are not payable at initial issue of a base orthosis. When claims for code(s) L4002 – L4130, and L4392 are billed at the time of initial issue of a base orthosis, the addition code(s) will be rejected as incorrect coding.
  • Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items.

Revision History Explanation
Revision Effective Date: 01/01/2011
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Preamble language
Revised: Clarified noncoverage statements for L4392, L4394, L4396 and L4398
CODING GUIDELINES:
Added: Definition of L4631
Revised: Clarified proper coding instructions based on brace use

Revision Effective Date: 01/01/2010
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Information on code A4466
CODING GUIDELINES:
Deleted: Reference to invalid code L2770

Revision Effective Date: 12/01/2009
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Information on code A9283
CODING GUIDELINES:
Revised: Instructions for coding A9283
Revised: Instructions for code L2770
Revised: Instructions for coding concentric adjustable torsion joints
Revised: Instructions for RT/LT modifiers

Revision Effective Date: 06/01/2009
CODING GUIDELINES:
Deleted: Code L2035 from the custom-fabricated orthoses list
Deleted: Codes K0628 and K0629 from the list used in diabetic foot problems management
Added: Codes A5512 and A5513 to the list used in diabetic foot problems management
Added: Code L4392 to list of codes rejected as incorrect coding when billed with initial issue of a base orthosis.

Revision Effective Date: 04/01/2009
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Noncoverage language for elastic support garments
CODING GUIDELINES:
Deleted: Code L1901 from the prefabricated orthoses list and from the from ankle-foot orthosis worn by ambulatory patients.
Added: Code L2770 is invalid for dates of service (DOS) on or after 07/01/2008
Revised: Removed Column I/Column II table in lieu of statement about billing replacement codes at time of initial issue.
Revised: SADMERC to PDAC

03/01/200 – In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) Article A19885 from DME PSC TrustSolutions (77012) Article A19885.

Revision Effective Date: 01/01/2008
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Noncoverage statement regarding A9283.
CODING GUIDELINES:
Added: Definition of A9283

Revision Effective Date: 07/01/2007
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Changed title of previous Therapeutic Shoes for Diabetics LMRP, to the new LCD title – Therapeutic Shoes for Persons with Diabetes.
CODING GUIDELINES:
Changed title of previous Therapeutic Shoes for Diabetics LMRP, to the new LCD title – Therapeutic Shoes for Persons with Diabetes.
Removed: Reference to DMERC.

06/01/2007 – In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 – In accordance with Section 911 of the Medicare Modernization Act of 2003, this article was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006
CODING GUIDELINES:
Added: L2034
Deleted L2039

Revision Effective Date: 04/01/2005
HCPCS CODES AND MODIFIERS:
Added: L2005, L2232, L4002
Revised: L2035, L2036, L2037, L2038, L2039, L2320, L2330, L2755, L2800, L4040, L4045, L4050, L4055
Deleted: L2435

Revision Effective Date: 07/01/2004
LMRP converted to LCD and Policy Article
Coding Guidelines: Revised definition of L4396 to include use in the treatment of plantar fasciitis.

08/05/2011 – The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.