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

2013-08 Updated LCD L11527, Part 4

KYDEX-PRO

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LEEDerGroup.com

  • 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 beneficiary in mind. A
    prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific beneficiary (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 beneficiary 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 described by codes L1900, L1910-L1990 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 and ankle gauntlets described by codes L1902 – L1907. Code L1906 describes a multiligamentous ankle support that provides control of the ankle joint between the medial and lateral malleoli while allowing for dorsiflexion and plantar flexion by way of a hinge or joint mechanism. This off-the-shelf ankle support includes a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation. This, in conjunction with wraparound straps and the inherent gauntlet design, offers areas of multiligamentous support as described by the code. There are no additional HCPCS codes for this type of prefabricated ankle orthosis. Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification Matrix. L1960 describes an Ankle Foot Orthosis (AFO) provides ankle control for beneficiaries with musculoskeletal or neuromuscular dysfunction. The AFO is designed to provide rigid immobilization of the ankle-foot complex in the sagittal, coronal, and transverse planes. The custom fabricated solid ankle AFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. L2340 is a pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials. Code L2755 describes an addition to a lower extremity orthosis composed of high strength and/or lightweight material such as kevlar, carbon fiber or other laminated or impregnated composite material.
    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:
    1. Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45°;
    and,
    2. Applies a dorsiflexion force to the ankle; and,
    3. Used by a beneficiary who is minimally ambulatory, or nonambulatory; and,
    4. 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:
    1. Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and,
    2. Not designed to accommodate an ankle with a plantar flexion contracture; and,
    3. Used by a beneficiary who is nonambulatory; and,
    4. 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:
    1. Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and,
    2. Allows for varus or valgus deformity correction; and,
    3. Contains a rocker bottom sole with a custom arch support; and,
    4. Incorporates a rigid anterior tibial shell; and,
    5. Used by a beneficiary who is ambulatory; and,
    6. 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., noncustom-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 beneficiary is ambulatory. Code L4396 is used for an ankle-foot orthosis which is worn
    when a beneficiary is nonambulatory, or minimally ambulatory.
    Code L4398 is used for an ankle-foot orthosis which is worn when a beneficiary 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.
    Foot orthotics are shoe inserts that do not extend above the ankle. The correct codes for foot orthotics provided
    for beneficiaries 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).
    All claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint for any
    condition other than an assistive function to joint extension motion must be coded as Durable Medical Equipment
    using code E1810 (dynamic adjustable knee extension/flexion device). If a concentric adjustable torsion style
    mechanism in the knee joint is used solely to provide an assistive function for joint extension, it must be coded as
    L2999 (See AFO/KAFO Local Coverage Determination Indications and Limitations of Coverage and/or Medical
    Necessity).
    All claims for devices that contain a concentric adjustable torsion style mechanism in the ankle joint for any
    condition other than an assistive function to joint plantar- or dorsiflexion motion must be coded as Durable
    Medical Equipment using code E1815 (dynamic adjustable ankle extension/flexion device). If a concentric
    adjustable torsion style mechanism in the ankle joint is used solely to provide an assistive function for joint
    plantar or dorsiflexion, it must be coded as L2999 (See AFO/KAFO Local Coverage Determination Indications and
    Limitations of Coverage and/or Medical Necessity).
    Claims for devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint and
    that are being used to treat any condition other than an assistive function to joint extension motion are not
    covered under the Braces benefit and will be denied as incorrect coding when billed using code L2999 (See
    AFO/KAFO Local Coverage Determination Indications and Limitations of Coverage and/or Medical Necessity).
    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 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.
    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.
    Code L4205 (Repair of orthotic device, labor component, per 15 minutes) may only be billed for time involved
    with the actual repair of an orthosis or for medically necessary adjustments made more than 90 days after
    delivery. Code L4205 must not be used to bill for time involved with other professional services including, but not
    limited to:
    • Evaluating the beneficiary
    • Taking measurements, making a cast, making a model, use of CAD/CAM
    • Making modifications to a prefabricated item to fit it to the individual beneficiary
    • Follow-up visits
    • Making adjustments at the time of or within 90 days after delivery
    Suppliers must distinguish between repair and replacement of an orthosis. When an orthotic is replaced, there is
    no separate billing for the above services because reimbursement for these services is included in the allowance
    for the replacement item.
    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.
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    Coding Information
    No Coding Information has been entered in this section of the article.
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    Other Information
    Other Comments
    3/1/2008- In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME
    MAC NHIC (16003) Article A19806 from DME PSC TriCenturion (77011) Article A19806.
    Revision History Explanation
    Revision Effective Date: 01/01/2013 (February Publication)
    CODING GUIDELINES:
    Deleted: Height definition for AFO codes L1900, L1910-L1990
    Revision Effective Date: 01/01/2013
    CODING GUIDELINES:
    Revised: Height definition for AFO codes L1900, L1910-L1990
    Revision Effective Date: 07/01/2012 (July Publication)
    CODING GUIDELINES:
    Deleted: Coding verification for codes L1930, L1932, L1940, L1960, L1970 and L1971 (For HCPCS code L1960,
    coding verification is also deleted effective with 01/01/2012 revision due to published in error.)
    Revision Effective Date: 07/01/2012 (May Publication)
    CODING GUIDELINES:
    Added: Coding guidelines for L1906
    Revised: Coding guidelines for concentric adjustable torsion joints (Effective 03/13/2012)
    Added: Coding verification for codes L1906, L1930, L1932, L1940, L1960, L1970 and L1971
    Added: Repair and replacement guidelines
    Revision Effective Date: 01/01/2012
    NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
    Added: Standard Language
    Added: Reference for Supplier Standards, Quality Standards and Accreditation requirements in 42 CFR.
    CODING GUIDELINES:
    Changed: Word “Patient? to “Beneficiary?
    Added: Standard Language
    Added: Coding verification information for code L1960
    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 for 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.
    Removed: Column I/Column II table in lieu of statement about billing replacement codes at time of initial issue.
    Revised: SADMERC to PDAC.
    03/01/2008- In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to
    DME MAC NHIC (16003) Article A19806 from DME PSC TriCenturion (77011) Article A19806.
    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 TriCenturion (77011) from DMERC Tricenturion (77011).
    Revision Effective Date: 01/01/2006
    CODING GUIDELINES:
    Added: L2034
    Deleted: L2039
    Revision Effective Date: 04/01/2005
    CODING GUIDELINES:
    Added: L4002 to correct coding table.
    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.
    Related Document(s)
    LCD
    L11527 – Ankle-Foot/Knee-Ankle-Foot Orthosis opens in new window
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    Updated on 02/04/2013 with effective dates 01/01/2013 – N/A
    Updated on 02/01/2013 with effective dates 01/01/2013 – N/A
    Updated on 11/29/2012 with effective dates 01/01/2013 – N/A
    Updated on 07/12/2012 with effective dates 07/01/2012 – N/A
    Updated on 06/29/2012 with effective dates 07/01/2012 – N/A
    Updated on 05/04/2012 with effective dates 07/01/2012 – N/A
    Updated on 05/01/2012 with effective dates 07/01/2012 – N/A
    Updated on 03/01/2012 with effective dates 01/01/2012 – N/A
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    Updated on 12/10/2010 with effective dates 01/01/2011 – N/A
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