Clinicians! Are You Ordering (AFO/KAFO) Orthoses for Your Patients? - JA DME

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are offering guidance to help suppliers provide a lower limb orthosis to your patient. Medicare must be able to verify there is medical record documentation to support the orthosis you are prescribing.

Medicare coverage requires the patient's medical record to show the orthosis is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Local Coverage Determination (LCD) Coverage Criteria Documentation Requirements

AFOs Not Used During Ambulation:

An L4396 or L4397 (static or dynamic positioning AFO) is covered if either all of criteria 1 – 4 or criterion 5 is met:

• Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the Local Coverage Determination (LCD) related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and,
• Reasonable expectation of the ability to correct the contracture; and,
• Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; and,
• Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.
• The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses)

KAFOs Used During Ambulation:

Ankle-foot orthoses described by codes L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

• Require stabilization for medical reasons, and,
• Have the potential to benefit functionally.

Knee-ankle-foot orthoses described by codes L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136, and L4370 are covered for ambulatory beneficiaries for whom an AFO is covered and for whom additional knee stability is required.

Custom Fabricated AFOs and KAFOs (HCPCS Codes L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2106, L2108, L2126, L2128, L4631):

Ankle-foot orthoses and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria and one of the following criteria are met:

• The beneficiary could not be fit with a prefabricated AFO; or,
• The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
• There is a need to control the knee, ankle or foot in more than one plane; or,
• The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating to prevent tissue injury; or,
• The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

For all coverage criteria, see the Ankle-Foot/Knee-Ankle-Foot Orthosis LCD L33686 and Policy Article A52457.

Medicare requires a Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) for some of these braces. The treating practitioner must complete the WOPD within six months after the face-to-face encounter. (See the Required Face-to-Face Encounter and WOPD List here.)

The SWO/WOPD must contain the elements listed below. Assist your patient by providing the order and documentation to substantiate need in a timely manner. In addition to the "reasonable and necessary" criteria outlined in the LCD there are further payment rules related to documentation requirements. For details related to those documentation requirements, review the Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).

Standard Written Order (SWO)

A valid order must have the following elements:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., ankle foot orthosis), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
  • For equipment – In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
  • For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature

Medicare requires that all HCPCS codes that appear on the Required Prior Authorization List must be submitted for prior authorization before delivery and claim submission.

LCDs and Policy Articles for lower limb orthoses can be located on the DME MAC contractor websites.