You can collapse such groups by clicking on the group header to make navigation easier. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. of the Medicare program. Subscribe to stay up-to-date on our latest posts. Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed must be coded using the applicable specific HCPCS code for the type of product. There are numerous design options available that make usage of the Orthosis both functional and comfortable. The orthosis may or may not include joints or hinges for additional support. Green Bay, WI 54301, Hours: It may involve the incorporation of some prefabricated components. A knee ankle foot orthosis (KAFO) is a custom made brace used to support muscles, immobilize joints, and/or correct the position of your knee, foot, and ankle. Included in the code are closure components. support items made of material such as neoprene or spandex (elastane, Lycra]) (not all-inclusive)) that contain stays and/or panels must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE). What is a KAFO? 8 AM 4:30 PM Included in the code are closure components. Components also available separately. A detailed examination and assessment of the patient allows us to suggest the best available component combination. This information will be corroborated by the functional evaluation in the orthotist or prosthetists records. Included in the code are closure components. Primary construction is a plastic full-length rigid foot plate, rigid shell with Anterior calf cuff typically extending from mid-shin region to tibial tubercle. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. Revenue Codes are equally subject to this coverage determination. Code L4631 describes a Charcots restraint orthotic walker (CROW) orthosis. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically. Applications are available at the American Dental Association web site. Items that are primarily constructed of elastic or other stretchable materials (e.g. Refer to the LCD section on Coverage Indications, Limitations, and/or Medical Necessity for other coverage criteria and payment information.For HCPCS codes L4392, L4396 and L4397: For the specific HCPCS codes indicated above, all ICD-10 codes that are not specified in the preceding section. This AFO is custom fabricated per the DMEPOS quality standards, Appendix C. L1945 (ANKLE-FOOT ORTHOSIS (AFO), PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM FABRICATED) describes a custom fabricated AFO designed to control inversion, eversion, dorsiflexion, plantarflexion, and horizontal rotation motions of the ankle foot complex. McDaid C, et al. They are prescribed for a number of reasons, these include: To provide support to weakened or weakening joints and muscles. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of CMS internally within your organization within the United States for the sole use by yourself, employees and agents. Foot orthotics are shoe inserts that do not extend above the ankle. A SCKAFO locks the knee joint during the stance phase and allows free rotations during the swing phase of ambulation [ 2 ]. The AFO can be articulated at the ankle with various types of ankle joints that will limit or assist dorsiflexion and plantarflexion as needed. If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. A PCL with products which have received a coding verification can be found on the PDAC web site. Reg Vol 217):Added: Section and related information based on Final Rule 1713POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:Revised: ordering physicians to treating practitionersRevised: physicians to practitionersRevised: Format of HCPCS code references, from code spans to individually-listed HCPCSCODING GUIDELINES:Revised: Format of HCPCS code references, from code spans to individually-listed HCPCSAdded: Coding Guidelines for L1900, L1902, L1904, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1970, L1971, L1980, and L1990Revised: L1906 Coding GuidelineRevised: L2006 Coding Guideline per quarterly HCPCS code updateRemoved: HCPCS K0903Added: HCPCS A5514, crosswalk from K0903Removed: Reference of effective DOS for K0903Added: Reference of effective DOS for A551402/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. The AFO is designed to provide rigid immobilization of the ankle-foot complex in the sagittal, coronal, and transverse planes. CMS and its products and services are not endorsed by the AHA or any of its affiliates. While there are several common indications for such an Orthosis muscle weakness & paralysis of the leg are the ones most frequently identified. Foot orthotics, when considered for coverage as integral components of a covered leg brace, must be billed using L-codes (L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090) (refer to the Orthopedic Footwear policy for more information). Included in the code are closure components. This revision is to an article that is not a local coverage determination. Payment for ankle-foot orthoses or knee-ankle foot orthoses delivered to a beneficiary in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if: The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and, As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Primary construction are two metal uprights (medial and lateral) joined to a rigid calf band, free motion ankle joints, and stirrup component attached to an orthopedic shoe. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.General RequirementsThe supplier must include on the claim line the diagnosis code(s) for HCPCS codes L4396, L4397, L4392 and L4631.For a custom-fabricated orthosis, there must be documentation in the supplier's records to support the medical necessity of that type device rather than a prefabricated orthosis. This AFO is custom fabricated per the DMEPOS quality standards, Appendix C. L1971 (ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a prefabricated AFO designed to control inversion, eversion, dorsiflexion, plantarflexion, and horizontal rotation motions of the ankle foot complex. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. The KAFO aims to make standing and walking easier by: Controlling joint instability A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Included in the code are closure components and soft interface. End User Point and Click Amendment: The brace ordered by your provider is designed to help support your knee, ankle, and foot. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. First, it acts as a supportive device for walking through different gait stages. Our facility is a full service Calgary Orthotics Clinic offering custom foot orthotics, ankle braces (AFO), knee braces, scoliosis braces, and other bracing solutions. 03/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. The UTX Swing Knee Ankle Foot Orthosis, was designed and developed by Dr. Nils Van Leerdam, of Ambroise Holland bv. The custom fabricated KAFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. The knee joint can be solid (locked) or can allow for a certain range of motion. When claims for code(s) L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110,L4130, and L4392 are billed at the time of initial issue of a base orthosis, the addition code(s) will be rejected as incorrect coding.Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. Federal government websites often end in .gov or .mil. This document addresses orthoses for the ankle-foot or the knee-ankle-foot. To learn more, visit our Privacy Statement. The orthosis is provided to the beneficiary within two days prior to discharge to home; and. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. derivative work without the written consent of the AHA. Unless otherwise instructed, begin by wearing the brace one to two hours your first day. There are no additional HCPCS codes for this type of prefabricated ankle foot orthosis. ICD-10-CM Codes that Support Medical Necessity, ICD-10-CM Codes that DO NOT Support Medical Necessity, A55426 - Standard Documentation Requirements for All Claims Submitted to DME MACs, L33686 - Ankle-Foot/Knee-Ankle-Foot Orthosis, Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy, Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy, Type 1 diabetes mellitus with diabetic neuropathic arthropathy, Type 2 diabetes mellitus with diabetic neuropathic arthropathy. L1907 (ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED) describes a custom fabricated AO designed to control motion of the ankle and mid-foot. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. The purpose of an orthosis (rigid or semi-rigid brace) is to support a weak or deformed body part, or to restrict or eliminate motion in a diseased or injured part of the body. You may have been provided with a knee-ankle-foot orthosis, or KAFO, which has been designed to meet your individual needs. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code. The orthosis may or may not include joints or hinges for additional support. Diagnosis codes for Procedure Codes L4392, L4396 and L4397, Internal Medical Policy Committee 7-22-2020 Annual Review, Internal Medical Policy Committee 9-21-2020 Removed coding from policy statements-no changes to criteria, Internal Medical Policy Committee 9-21-2021 Annual Review-no changes in criteria, Internal Medical Policy Committee 9-28-2022 Annual Review-no changes in criteria. Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary. This provided stability to the knee to prevent involuntary flexion, but caused other associated problems like muscle atrophy and increased energy expenditure in gait. Also, you can decide how often you want to get updates. Fri. By Appointment Only . Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted. They can have knee and/or ankle joints but depending on the condition could possibly be completely without motion. Fargo, N.D., 58121. This revision is to an article that is not a local coverage determination. Primary construction is of molded plastic designed to control inversion and eversion, and horizontal rotation motions while allowing dorsiflexion and plantarflexion motion of the ankle joint. This information must be available upon request.When providing orthoses suppliers must: Provide the product that is specified by the treating practitioner, Be sure that the treating practitioner's medical record justifies the need for the type of product (i.e., prefabricated versus custom fabricated), Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting, Have detailed documentation in the supplier's record that justifies the code selected. This AFO can be constructed from flexible and strong thermosetting materials, thermoplastics, or composite type materials. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding. If a concentric adjustable torsion style mechanism in the ankle joint is used solely to provide an assistive function for joint plantar or dorsiflexion, it must be coded as L2999 (See Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD).Claims for devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint and that are being used to treat any condition other than an assistive function to joint extension motion are not covered under the braces benefit and will be denied as incorrect coding when billed using code L2999 (See Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD).Code A9283 (FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH) is used for an item that is designed primarily to reduce pressure on the sole or heel of the foot. This provided stability to the knee to prevent involuntary bending of the knee, but caused other associated problems such as muscle atrophy and increased energy expenditure while walking. The parallel HCPCS code types are: Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient may be considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.Kits are: Elastic and Similar Stretchable MaterialsFor items where the HCPCS code specifies elastic or other similar terminology for stretchable material, use the code that is most applicable to the item. KAFO also known as polio leg caliper is a long-leg orthosis that spans the knee ankle and foot in an effort to stabilize the joints & assist the muscles of the leg. If a concentric adjustable torsion style mechanism in the knee joint is used solely to provide an assistive function for joint extension, it must be coded as L2999 (See Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD).All claims for devices that contain a concentric adjustable torsion style mechanism in the ankle joint for any condition other than an assistive function to joint plantar- or dorsiflexion motion must be coded as durable medical equipment using code E1815 (DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). Trimmable polyethylene components offer more comfortable total contact, Lightweight, durable polyethylene femoral and tibial components with a low density tongue, 2020 Riverside Dr. (3rd Floor) (See definitions below in CODING GUIDELINES.) Revision Effective Date: 01/01/2017CODING GUIDELINES:Revised: Code pairs to accurately reflect parallel codesUpdated: HCPCS code narratives to align with HCPCS code tableAdded: Walking boot add-on bundling information. A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in an individual with foot drop who is non ambulatory because there are other more appropriate treatment modalities. Primary construction is a single metal upright (medial or lateral) joined to a rigid calf band, free motion ankle joint, and stirrup component attached to an orthopedic shoe. & Sun. Automatic knee lock is activated by any method such as mechanical or electrical. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. The parallel code sets, when available for identical products, are only differentiated by the nature of the final fitting performed at the time of delivery. Proximal uprights provide surface area contact for stabilization of the footplate and ankle joints. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. There are no additional HCPCS codes for this type of prefabricated ankle foot orthosis. NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

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