RAC Region A contractor Performant is targeting DME suppliers for Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot Orthoses (KAFO). AFOs 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. KAFOs are covered for ambulatory patients for whom an ankle-foot orthosis is covered and for whom additional knee stability is required. Both types of devices can be pre- or custom-fabricated.

The issue is that claims for HCPCS codes which describe additions for custom-fabricated orthoses will be denied when billed with prefabricated AFOs and KAFOs HCPCS base codes listed in the Local Coverage Determination (LCD) policy. For custom-fabricated orthoses to be even covered by Medicare, there must be detailed documentation in the treating physician’s records to support the medical necessity of a custom-fabricated rather than a prefabricated orthosis. There must be information corroborated by the functional evaluation in the physician’s records and it must be available upon request.

Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2030, L2034, L2036-L2108, L2126-L2128, and L4631 describe custom-fabricated orthoses and 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 and must not be used for custom-fabricated orthoses.

To avoid denials on AFO/KAFO claims, the right (RT) and left (LT) modifiers must be used with 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 two units of service. Claims billed without modifiers RT and/or LT will be rejected as incorrect coding.

RAC issues for the week of June 10–June 14, 2013:

RAC Region A Performant        

DME Supplier Claim Types

§  Ankle-Foot Orthosis (AFO) and Knee-Ankle-Foot Orthosis (KAFO), Custom vs. Prefabricated – Jurisdiction A – Claims for HCPCS codes L2232, L2320, L2330, L2387, L2755, L2800, L4040, L4045, L4050, and L4055, which describe additions for custom-fabricated orthoses, will be denied when billed with prefabricated Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot Orthoses (KAFO) HCPCS base codes listed in NHIC's Local Coverage Determination (LCD) L11527 and related Article A19806, and NHIC's LCD L27263 and related Article A46762.

RAC Region D HDI

DME Supplier Claim Types

§  Pre-Payment Review of MS-DRG 638 – Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MSDRG 638, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

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