Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)

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).WALKING BOOTSPrefabricated walking boots are coded using codes L4360, L4361, L4386 or L4387.These codes describe complete products.Claims for add-on codes used with walking boots coded L4360, L4361, L4386 or L4387 will be denied as unbundling.Certain products may have both covered and non-covered uses, as defined by the braces benefit category, and must be coded based on the beneficiarys condition. For example, when used as a brace for the treatment of an orthopedic condition, walking boots are coded L4360, L4361, L4386, L4387 and L4631. However, walking boots must be coded A9283 when used solely for the prevention or treatment of a lower extremity ulcer or pressure reduction.OTHER DEVICESCode 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. It may be a shoe-like item, an item that is used inside a shoe and may or may not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated. Code A9283 does not include items that meet the definition of a therapeutic shoe for diabetes (A5500, A5501).When using code A9283, there is no separate billing using addition codes. Replacement liners for devices billed with A9283 must be billed with code A9270 (NON-COVERED ITEM OR SERVICE).Code A9285 (INVERSION/EVERSION CORRECTION DEVICE) is designed to provide off-loading pressure to the knee for the treatment of knee osteoarthritis. The device is applied at the foot and extends across the ankle to apply pressure to the side of the leg below the knee. It does not provide any support at the ankle.REPAIR/REPLACEMENTCode L4205 (REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES) may only be billed for time involved with the actual repair of an orthosis or for medically necessary adjustments made more than 90 days after delivery. Code L4205 must not be used to bill for time involved with other professional services including, but not limited to:Evaluating the beneficiaryTaking measurements, making a cast, making a model, use of CAD/CAMMaking modifications to a prefabricated item to fit it to the individual beneficiaryFollow-up visitsMaking adjustments at the time of or within 90 days after deliverySuppliers must distinguish between repair and replacement of an orthosis. When an orthotic is replaced, there is no separate billing for the above services because reimbursement for these services is included in the allowance for the replacement item.Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier's record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.The allowance for the labor involved in replacing an orthotic component that is coded with a specific L-code is included in the allowance for that component. The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous code L4210 is separately payable in addition to the allowance for that component.Addition codes L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110,L4130, and L4392 are for billing of replacement components and are not payable at initial issue of a base orthosis. 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.HCPCS codes L4050 and L4055 do not describe replacement soft interfaces used with contracture orthoses.Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC web site or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC web site. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after April 1, 2012:L1906Effective for claims with dates of service on or after January 1, 2020:L2006If 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.