Concentric adjustable torsion style mechanisms (L2999) used to assist knee joint extension are considered medically necessary and, therefore, covered for individuals who require knee extension assist in the absence of any coexisting joint contracture.
Concentric adjustable torsion-style mechanisms (L2999) used to assist ankle joint plantarflexion or dorsiflexion are considered medically necessary and, therefore, covered for individuals who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture.
ADDITIONS
Additions to an AFO/KAFO are considered medically necessary and, therefore, covered when the AFO/KAFO is considered medically necessary according to the criteria listed in this policy. Refer to Attachment A for a list of corresponding codes.
EVALUATION AND FITTING
Evaluation of the individual, measurement and/or casting, and fitting of the orthosis are included in the allowance for the orthosis. There is no separate reimbursement for these services.
REPAIR AND REPLACEMENT
Repair and replacement for AFOs/KAFOs are considered medically necessary and, therefore, covered when the criteria listed in this policy are met for the specific orthosis. In addition, the requirements listed in the Repair and Replacement of Durable Medical Equipment (DME) policy must be met.
If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no reimbursement will be made for the excess expense.
The allowance for the labor involved for the replacement for an orthotic component that is coded with a specific Healthcare Common Procedure Coding System (HCPCS) L-code, includes includes fitting and adjustment, is included in the reimbursement for that component.
The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous HCPCS code L4210 is separately reimbursable in addition to the allowance for that component.
The reason for the repair or replacement must be documented in the supplier's record.
NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
Orthotic training may include teaching the individual regarding a wearing schedule, placing and removing the orthosis, skin care and performing tasks while wearing the device. It is not appropriate to include the time spent assessing, measuring or fitting, fabricating or modifying, or making the orthotic in the time spent providing orthotic training. Only the time spent actually training the individual should be included in the orthotic training service.
Evaluation of the individual, measurement and/or casting, and fitting/adjustments of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.
When providing off-the-shelf (OTS) or custom-fitted orthotics, suppliers must:
- Provide the product that is specified by the ordering professional provider, i.e., type of orthosis and method of fitting (OTS or custom fitted).
- Be sure that the medical record justifies the need for the type of product and method of fitting.
- Be sure only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting.
- Have detailed documentation that justifies the code selected for custom fitted versus OTS.
When providing custom-fabricated orthotics, there must be documentation in the supplier's records to support the medical necessity of that type device rather than a prefabricated orthosis.
If an ankle contracture splint/static or dynamic AFO is used for the treatment of a nonfixed ankle plantar flexion contracture, the pretreatment passive range of motion should be measured with a goniometer and documented in the medical record. There should also be documentation that an appropriate stretching program is being overseen by professional staff (in a nursing facility) or a caregiver (at home).
The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.
STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.
PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.
CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.
For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.
If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.
BILLING REQUIREMENTS
It is not appropriate to report L2999 for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any joint contracture.
Replacement components that do not have a unique HCPCS code must be billed with a “not otherwise specified" code (L2999). The claim must include a description of the component provided, the reason for replacement, and the HCPCS code or narrative description of the base orthosis.
HCPCS code L4205 may only be billed for time involved with the actual repair of an orthotic, or for medically necessary adjustments.
HCPCS code L4205 must not be used to bill for time involved with other professional services including those listed below. Reimbursement for these services is included in the allowance for the HCPCS codes that describe the orthosis.
- Evaluating the individual
- Taking measurements, making a cast, making a model, use of computer-aided design/computer-aided manufacturing (CAD/CAM)
- Making modifications to a prefabricated item to fit it to the individual
- Follow-up visits
- Making adjustments at the time of or within 90 days after delivery
HCPCS code L4210 must not be used for casting supplies or other materials used in the fitting or fabrication of an orthosis.
Addition codes L4002-L4130, and L4392 are for billing of replacement components and are not payable at initial issue of a base orthosis.
