PROVIDER COMPLIANCE TIPS FOR ORDERING LOWER LIMB ORTHOSES
April 25, 2019
PROVIDER TYPES AFFECTED
Physicians and other practitioners who write prescriptions for lower limb orthoses
The 2018 Medicare Fee-For-Service improper payment rate for lower limb orthoses was 60.3 percent, representing a projected improper payment more than $235.2 million.
REASONS FOR DENIALS
Insufficient documentation errors accounted for 84.7 percent of improper payments for lower limb orthoses for the 2018 reporting period. Additional types of errors included no documentation (0.4 percent), medical necessity (5.8 percent), and other (9.0 percent) for this service.
TO PREVENT DENIALS
Medicare covers ankle-foot orthoses not used during ambulation described by codes L4396 or L4397 if you meet either all of criteria 1–4 or criterion 5:
Plantar flexion contracture of the ankle (see Diagnosis Codes That Support Medical Necessity, Group 1 Paragraph page 9 LCD L33686) with dorsiflexion on passive range of motion testing of at least 10 degrees (for example, a non-fixed contracture); Note: To support this criterion, documentation must demonstrate the beneficiary’s pre-treatment passive range of motion as measured by a goniometer, and be reflective of an appropriate stretching program carried out by professional staff (in a nursing facility) or a caregiver (at home)
Reasonable expectation of the ability to correct the contracture
Contracture interferes or is expected to interfere significantly with the beneficiary’s functional abilities
Used as a component of a therapy program, which includes active stretching of the involved muscles and/or tendons
The beneficiary has plantar fasciitis (see Diagnosis Codes That Support Medical Necessity Group 1 Codes section)
Medicare covers ankle-foot orthoses used during ambulation described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387, and L4631 for ambulatory beneficiaries with weakness or deformity of the foot and ankle who:
Require stabilization for medical reasons
2. Have the potential to benefit functionally
Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.
For prefabricated orthoses (L1902, L1906, L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4350, L4360, L4361, L4370, L4386, L4387 and L4396-L4398), there is no physical difference between orthoses coded as custom fitted versus those coded as off-the-shelf.
The differentiating factor for proper coding is the need for minimal self-adjustment at the time of fitting by the beneficiary, caretaker for the beneficiary, or supplier.
This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training.
Code items requiring minimal self-adjustment as off-the-shelf orthoses. For example, adjustment of straps and closures and bending or trimming for final fit or comfort (not all-inclusive) fall into this category.