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For KAFOs, the documentation must not only reflect ankle and foot instability but also document additional instability at the knee warranting a KAFO. Documentation of knee instability alone does not meet the coverage criteria for an AFO. The patient must first qualify for an AFO and then have additional, documented instability at the knee.
The Policy Article states that AFOs and KAFOs are covered under the Medicare Braces benefit category and therefore must meet the definition of a brace to be covered.
adjustable torsion-style mechanisms. While this type of joint is eligible for coverage when used to assist joint function in AFOs and KAFOs for ambulatory patients, it must be billed as L2999. When these joints are used for contracture management, they are covered under the DME benefit and may only be billed using the appropriate “E” codes, which are typically only reimbursed as rental items. The LCD then addresses the standard prescription and proof of delivery requirements that exist for all Medicare-covered services. Finally, the LCD reiterates that if a custom AFO or KAFO is provided, there must be detailed documentation in the physician’s records that supports a custom-fabricated orthosis rather than a prefabricated orthosis.
The Policy Article The next section of the LCD describes the specific criteria that must be documented in the medical record in order for a custom-fabricated or molded-to-patient model AFO or KAFO. One of the following criteria must be well documented: • The beneficiary could not be fit with a prefabricated AFO. • The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six months). • There is a need to control the knee, ankle, or foot in more than one plane. • The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury. • The beneficiary has a healing fracture that lacks normal anatomical integrity or anthropometric proportions. While only one of these criteria must exist, failure to properly document its existence may result in an unnecessary claim denial. The next section of the LCD addresses the use of concentric
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O&P Almanac OCTOBER 2013
An often overlooked but very important component of the medical policy for AFOs and KAFOs is the Policy Article. Unlike the LCD, which addresses issues concerning medical necessity, the Policy Article provides important definitions and information regarding situations where an AFO or KAFO is statutorily non-covered. The Policy Article states that AFOs and KAFOs are covered under the Medicare Braces benefit category and therefore must meet the definition of a brace to be covered. This definition
is recorded as “a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting motion in a diseased or injured part of the body. It must provide support and counterforce on the limb or body part that it is being used to brace.” Devices that do not meet the requirements of this definition are statutorily non-covered, meaning there is simply no benefit available. An example of this situation that is addressed in the Policy Article is AFOs that are used solely to prevent or treat a pressure ulcer. Since these devices do not meet the statutory definition of a brace, they cannot be covered as one regardless of their effectiveness in treating the ulcer. The Policy Article provides clear definitions of prefabricated orthoses, custom-fabricated orthoses, and several specific codes for base AFOs and addition codes. It is important to review and understand these definitions when making decisions on how to properly code the services you are providing to Medicare patients. The key to not only receiving reimbursement for AFOs and KAFOs but preventing overpayment notices and recoupment down the road begins with a thorough understanding of the Medicare policy governing their coverage. Though we covered some of the important components of the policy, a regular review of the policy remains in your best interest. a Joe McTernan is AOPA’s director of coding and reimbursement services. Reach him at jmcternan@ aopanet.org.