The purpose of a brace is to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
|Medicare Advantage Medical Policy Bulletin|
|Section:||Orthotic & Prosthetic Devices|
|Effective Date:||June 1, 2009|
|Issued Date:||June 1, 2009|
The purpose of a brace is to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
Indications and Limitations of Coverage
Ankle-Foot Orthoses Not Used During Ambulation
A static ankle-foot orthosis (L4396) is covered if either all of criteria 1-4 or criterion 5 is met:
If a static ankle-foot orthosis 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).
If code L4396, static ankle foot orthosis, 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 six months. Additional interfaces will be denied as not medically necessary.
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses Used During Ambulation
Ankle-foot orthoses described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, and L4386 are covered for ambulatory patients with weakness or deformity of the foot and ankle, which require stabilization for medical reasons, and have the potential to benefit functionally.
Knee-ankle-foot orthoses described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory patients for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.
Ankle-foot orthoses and knee-ankle-foot orthoses that are molded-to-patient-model, or custom-fabricated, are covered for ambulatory patients when the basic coverage criteria listed above and one of the following criteria are met:
If the specific criteria for a molded-to-patient-model or custom-fabricated orthosis are not met, but the criteria for a prefabricated, custom fitted orthosis are met, payment will be based on the allowance for the least costly medically appropriate alternative.
Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the patient’s condition, or irreparable accidental damage is covered if the device is still medically necessary. The reason for the replacement must be documented in the supplier’s record.
Reasons for Noncoverage
A static ankle-foot orthosis and replacement interface will be denied as not medically necessary if the contracture is fixed. A static ankle-foot orthosis and replacement interface will be denied as not medically necessary for a patient with a foot drop but without an ankle flexion contracture. A component of a static ankle-foot orthotic that is used to address positioning of the knee or hip will be denied as not medically necessary because the effectiveness of this type of component is not established.
A static ankle-foot orthosis and replacement interface (L4392) is noncovered when it is used solely for the prevention or treatment of a heel pressure ulcer because for these indications it is 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). The provider can bill the member for the denied service.
A foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394) is not reimbursable. A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in a patient with foot drop who is nonambulatory because there are other more appropriate treatment modalities.
A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) is also noncovered when it is used solely for the prevention or treatment of a pressure ulcer because for these indications it is 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).
If the basic coverage criteria for an ankle-foot orthosis or knee-ankle-foot orthosis are not met, the orthosis will be denied as not medically necessary.
Additions to ankle-foot orthoses and knee-ankle-foot orthoses (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary.
Quantities of supplies greater than those described in the policy as the usual maximum amounts, in the absence of documentation clearly explaining the medical necessity of the excess quantities, will be denied as not medically necessary.
For an item to be considered for coverage under the brace 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. The provider can bill the member for the denied service.
When an ankle-foot orthosis or a knee-ankle-foot orthosis for an ambulatory patient and any related addition is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, it will be denied as noncovered. For example, codes L4360 and L4386 are ankle-foot orthoses that are referred to as walking boots. Walking boots used to provide immobilization as a treatment for an orthopedic condition or after orthopedic surgery are eligible for coverage under the brace benefit. When walking boots are used primarily to relieve pressure, especially on the sole of the foot, or are used for patients with foot ulcers, they are noncovered. The provider can bill the member for the denied service.
Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices; therefore, code L1901 will be denied as noncovered. The provider can bill the member for the denied service.
A foot pressure off-loading/supportive device (A9283) is denied as noncovered because there is no benefit category for these items. The provider can bill the member for the denied service.
Socks (L2840, L2850) used in conjunction with orthoses are noncovered. The provider can bill the member for the denied service.
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. The provider can bill the member for the denied service.
Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.
An order for each new or full replacement item must be signed and dated by the treating physician, kept on file by the supplier and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.
The order must list the unique features of the base code that is billed plus every addition that will be billed on a separate claim line. The medical record must contain information which supports the medical necessity of the item and all additions that are ordered. An order is not necessary for the repair of an orthosis.
Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the "Indications and Limitations of Coverge" section of this policy have been met and evidence of such is retained in the supplier's files and available upon request. If the requirements for the KX modifier are not met, the KX modifier must not be used.
The supplier must include on the claim for a static ankle-foot orthosis (L4396) or replacement interface material (L4392) the diagnosis code for the underlying condition.
For custom-fabricated orthoses, there must be documentation in the supplier’s records to support the medical necessity of that type device rather than a prefabricated orthosis. This information does not have to be routinely sent in with the claim, but must be available upon request.
If an ankle-foot orthosis or knee-ankle-foot orthosis is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and any related addition code. If a walking boot (L4360, L4386), static ankle-foot orthosis (L4396) or foot drop splint/recumbent positioning device (L4398) is used solely for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and to the code for the replacement liner (L4392, L4394). When the GY modifier is added to a code there must be a short narrative statement indicating why the GY modifier was used, e.g., “used to prevent pressure ulcer," or “used to treat pressure ulcer” or “used to treat edema.” This statement should be entered in the narrative field of an electronic claim or attached to a hard copy claim.
When code L2999 is billed, the claim must include a narrative description of the item (for custom fabricated items) or the manufacturer name and model name/number (for prefabricated items). For replacement components billed with miscellaneous code L2999, there must also be a procedure code or the manufacturer name and model name/number of the base orthosis.
A claim for code L4205 must include an explanation of what is being repaired. A claim for code L4210 must include a description of each item that is billed. This information should be entered in the narrative field of an electronic claim or attached to a hard copy claim.
All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.
When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, there must be documentation in the patient’s medical record supporting the medical necessity for the higher utilization. This information must be available upon request.
Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2030, L2034, L2036- L2108 and L2126-L2128 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, and L4386 are used for an ankle-foot orthosis which are 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 procedure 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 procedure code must be billed with a “not otherwise specified” code – L2999. Procedure 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. Multiple density foot orthotics used in the management of diabetic foot problems are coded A5512 and A5513.
Code L2770 (Addition to lower extremity any material - per bar or joint) is invalid for claim submission.
Claims for prefabricated or custom-fabricated devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint and that are being used to treat a joint contracture 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. If a concentric adjustable torsion style mechanism in the knee or ankle joint is used in a custom-fabricated orthosis to provide an assist function to joint motion during ambulation, it should be coded as L2999.
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 LTRT modifiers and two units of service.
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, 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, L4392 are billed at the time of initial issue of a base orthosis, the addition code(s) will be rejected as incorrect coding.
Procedure Code Attachments
For codes L4392 and L4396:
Ankle Flexion Contracture
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.)
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 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.
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.
Foot Drop Splint/Recumbent Positioning Device
A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of the following characteristics:
Foot Pressure Off-Loading/Supportive Device
A foot pressure off-loading/supportive device, A9283, is designed primarily to reduce pressure on the sole or heel of the foot but that does not meet the definition of:
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.
A molded-to patient-model orthosis is a particular type of custom-fabricated orthosis in which an impression of the specific body part is made (by means of a plaster cast, CAD-CAM technology etc.) and this impression is then used to make a positive model (of plaster or other material) of the body part. The orthosis is then molded on this positive model.
Nonambulatory Ankle-Foot Orthosis
A nonambulatory ankle-foot orthosis may be an ankle contracture splint, night splint or a foot drop splint.
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 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 custom-fabricated orthosis is considered prefabricated.
Static Ankle-Foot Orthosis
A static ankle-foot orthosis (L4396) is a prefabricated ankle-foot orthosis which has all of the following characteristics: