evekhm/cms_iom_500 huggingface dataset:
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Items requiring more than minimal self-adjustment by a qualified practitioner (as defined in the CODING GUIDELINES below) are coded as custom fitted (L1910, L1930, L1932, L1951, L1971, L2035, L2112, L2114, L2116, L2132, L2134, L2136, L4360, L4386, L4396). Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.For a custom fabricated orthosis (L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2000, L2005, L2006, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2106, L2108, L2126, L2128, L4631), there must be detailed documentation in the treating practitioner's records to support the medical necessity of the custom fabricated orthosis rather than a prefabricated orthosis as described in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD. This information will be corroborated by the functional evaluation in the orthotist's records and the method of custom fabrication should adhere to the DMEPOS Quality Standards, Appendix C. This information must be available upon request.MODIFIERSGA, GZ, KX, LT, and RT MODIFIERS:Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section in the related LCD have been met and evidence of such is retained in the suppliers files and available to the DME MAC upon request.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
If all of the criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section of the related LCD have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions, and replacement parts. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.MISCELLANEOUSIf the item is custom fabricated and does not have a specific HCPCS code, a complete and clear description of the item, including what makes this item unique, and a breakdown of charges (material and labor used in fabrication) should be entered in the narrative field of an electronic claim or on Item 19 of a paper claim. (Refer to the LCD-related Standard Documentation Requirements article (A55426) for more information regarding billing of items with HCPCS codes that include miscellaneous, NOC, unlisted, or non-specified in their narrative descriptions.)A claim for code L4205 must include an explanation of what is being repaired. A claim for code L4210 must include a description of each item that is billed. This information should be entered in the narrative field of an electronic claim. (Refer to the REPAIR/REPLACEMENT section for more information regarding billing of L4205 and L4210 HCPCS codes.)All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.Refer to the Orthopedic Footwear policy for information on documentation requirements for shoes and related items which are an integral part of a brace.CODING GUIDELINESCUSTOM FABRICATEDA custom fabricated item is one that is individually made for a specific patient. No other patient would be able to use this item. A custom fabricated item is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, and/or other images (such as X-rays) of the body part.The fabrication may involve using calculations, templates, and components. This process requires the use of basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of uncut or unshaped sheets, bars, or other basic forms and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing prior to fitting on the patient. Custom-fabricated additions are appropriate only for custom-fabricated base orthotics and should not be billed with prefabricated base orthotics.Use of an additive manufacturing technique, CAD/CAM, or a similar manufacturing technique is not the sole requirement for a product to be designated as custom fabricated.Molded-to-Patient-ModelA particular type of custom fabricated device in which either:An impression (usually by means of a plaster or fiberglass cast) of the specific body part is made directly on the patient, and this impression is then used to make a positive model of the body part from which the final product is crafted; or,A digital image of the patients body part is made using CAD/CAM systems software. This technology includes specialized probes/digitizers and scanners that create a computerized positive model, and then direct milling equipment to carve a positive model. The device is then individually fabricated and molded over the positive model of the patient.Positive Model of the PatientA positive model is an exact replica of the actual body part for which the custom fabricated item is being constructed. A positive model can be produced by any of these methods:
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Positive Model of the PatientA positive model is an exact replica of the actual body part for which the custom fabricated item is being constructed. A positive model can be produced by any of these methods:Molded-to-patient-model, which is a negative impression taken of the patients body member and which is used to make a positive model rectification.CAD/CAM software, which uses digitizers to send surface contour data the practitioner uses to rectify or modify the model on the computer screen. The data showing the modified shape goes to a commercial milling machine that carves the rectified model.Direct formed model, in which the patient serves as the positive model. The device is constructed over the patients model, and is then fabricated to the patient. The completed custom fabrication is checked and all necessary adjustments are made.Additive ManufacturingAdditive manufacturing (such as 3D printing) is an advanced technology that constructs three-dimensional items modeled and designed from CAD software and/or from digital scanning. Additive manufacturing is an acceptable custom fabrication technique as long as it adheres to the CMS DMEPOS Quality Standards, Appendix C.Specialized TrainingSpecialized training is defined as training that provides knowledge, skills, and experience in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements.PREFABRICATEDA prefabricated orthosis is an item that is manufactured in quantity without a specific beneficiary in mind. A prefabricated orthosis may be considered an OTS or a custom fitted device that may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific beneficiary. An orthosis that is assembled from prefabricated components is considered prefabricated. It is inherent in the definition of prefabricated that a particular item is complete.Off-the-shelf (OTS) orthotics are:
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Items that are prefabricated.They may or may not be supplied as a kit that requires some assembly. 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.OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, and molding, assembling, or customizing to fit an individual.This fitting does not require expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary.The term minimal self-adjustment is defined at 42 CFR 414.402 as an adjustment the beneficiary, caregiver for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. See more than minimal self-adjustment definition below for additional information.Custom fitted orthotics are:Devices that are prefabricated.They may or may not be supplied as a kit that requires some assembly. 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.Classification as custom fitted requiresmore than minimal self-adjustment for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.This fitting at delivery does require expertise of a certified orthotist or an individual who has specialized training in the provision of the orthosis to fit the item to the individual beneficiary.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
In contrast to minimal self-adjustment, more than minimal self-adjustment is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.Correct coding of prefabricated orthoses is dictated by actions that take place at the time of fitting to the beneficiary, either custom-fitted (requiring expertise) or OTS (requiring minimal self-adjustment).Corresponding HCPCS Code SetsFor many prefabricated orthoses, corresponding sets of HCPCS codes are available which describe the identical types of items. The corresponding code sets, when available for identical products, are only differentiated by the nature of the final fitting performed at the time of delivery. The corresponding HCPCS code types are:HCPCS codes which describe PREFABRICATED, OFF-THE-SHELF. These HCPCS codes must be used when minimal self-adjustment is the extent of the fitting performed at delivery.HCPCS codes which describe PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE. These HCPCS codes must be used when more than minimal self-adjustment is necessary and performed at delivery.In the following table, the HCPCS codes located in Column I and Column II within the same row are considered a corresponding HCPCS code set. These codes represent identical products which are only differentiated by the nature of the final fitting performed at the time of delivery.Column IColumn IIL4360L4361L4386L4387L4396L4397
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Column IColumn IIL4360L4361L4386L4387L4396L4397For some prefabricated orthoses, corresponding sets of HCPCS codes (which describe the identical types of items) are not available. HCPCS codes with long descriptions of PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT describe custom fitted items. For these HCPCS codes there are no corresponding OTS codes. When the unique HCPCS code that most closely describes the product includes PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT in the HCPCS long description, the supplier must:Code the product using the unique HCPCS code, if the product was custom fitted at the time of delivery to the beneficiary; or,Code the product using a miscellaneous HCPCS code, if the product was not custom fitted at delivery to the beneficiary and, instead, was provided as OTS to the beneficiary. The miscellaneous HCPCS code for billing of AFOs and KAFOs is HCPCS code L2999.Kits are:A collection of components, materials, and parts that require further assembly before delivery of the final product.The elements of a kit may be packaged and complete from a single source or may be an assemblage of separate components from multiple sources by the supplier.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. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.For items where the HCPCS code does not specify elastic or other similar terminology for stretchable material, the following guidelines apply:
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra) (not all-inclusive)) must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).Items that are primarily constructed of elastic or other stretchable materials (e.g. 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).Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).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. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Items that are primarily of constructed 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 and that have stays and/or panels capable of providing the required 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. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and relevant coding guideline for the criteria applicable for each HCPCS code.Items that are not capable of providing the necessary immobilization or support to the body part for which it is designed (regardless of materials) must be coded using A9270 (NONCOVERED ITEM OR SERVICE).
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
ANKLE-FOOT-ORTHOSESAnkle-foot orthoses described by codes L1900, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980,L1990, extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthotics which are shoe inserts that do not extend above the ankle and ankle gauntlets described by codes L1902, L1904, L1906,L1907.L1900 (ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM FABRICATED) describes a custom fabricated AFO designed to control inversion, eversion, dorsiflexion, and plantarflexion motions of the ankle foot complex. Primary construction is of two springwire uprights, which are joined to a rigid calf band/cuff, and a component for attaching the orthosis to the sole of an orthopedic shoe. The springwire is contoured into a coiled spring below the ankle and above the shoe sole. The height of the rigid calf band/cuff terminates well-above the ankle (usually near the top of the calf) and the band/cuff is fastened around the lower leg above the ankle. The coiled springwire applies a spring force to resist plantarflexion motion and provide dorsiflexion assist. Included in the code are closure components, and attaching spring wire to the footwear. This AFO is custom fabricated per the DMEPOS quality standards, Appendix C.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
L1902 (ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated ankle orthosis (AO) designed to provide compression and resist motion of the ankle foot complex. Primary construction is a sleeve type device (gauntlet) with or without joints. The gauntlet encloses the foot and ankle from the longitudinal arch to at least just above the malleoli. Gauntlet closure may be straps, hook and loop, laces or equal. The orthosis may or may not include joints or hinges for additional support. There are no additional HCPCS codes for this type of prefabricated ankle orthosis.L1904 (ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, CUSTOM FABRICATED) describes a custom fabricated AO designed to provide compression and resist motion of the ankle foot complex. Primary construction is a sleeve type device (gauntlet) with or without joints. The gauntlet encloses the foot and ankle from the longitudinal arch to at least just above the malleoli. Gauntlet closure may be straps, hook and loop, laces or equal. The orthosis may or may not include joints or hinges for additional support. This AO is custom fabricated per the DMEPOS quality standards, Appendix C.L1906 (ANKLE FOOT ORTHOSIS, MULTILIGAMENTOUS, ANKLE SUPPORT, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated AFO which provides multi-directional support to the ankle ligaments while allowing free dorsiflexion and plantarflexion motion. Primary construction contains a rigid footplate with integral ankle joints and uprights extending above and below the ankle joints. Proximal uprights provide surface area contact for stabilization of the footplate and ankle joints. Additional support is from wraparound straps. Included in the code are closures from lacing, webbing, hook and loop, or equal, and additional support strapping. There are no additional HCPCS codes for this type of prefabricated ankle foot orthosis.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
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. 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. Included in the code are closure components, soft interface and padding. Trim lines extend from tips of toes to just above the malleoli. This AO is custom fabricated per the DMEPOS quality standards, Appendix C.L1910 (ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a prefabricated AFO designed to control dorsiflexion and plantarflexion motions of the ankle foot complex. Primary construction is a single flexible upright utilizing a removable clasp-type component attached to the heel portion of a shoe and a rigid calf band/cuff. Height of the rigid calf band/cuff terminates well above the ankle (usually near the top of the calf) and is fastened around the lower leg above the ankle. Included in the code are closure and clasp components. There are no additional HCPCS codes for this type of prefabricated ankle foot orthosis.L1920 (ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM FABRICATED) describes a custom fabricated AFO designed to control only the plantarflexion motion of the ankle foot complex. Primary construction is a single metal upright which has a pivoting attachment into a sole component attached to an orthopedic shoe. The single rigid upright is joined to a rigid calf band/cuff which terminates well-above the ankle (usually near the top of the calf) and is fastened around the lower leg above the ankle. The pivoting attachment has an integrated component(s) to stop plantarflexion ankle motion while always allowing free dorsiflexion motion.Included in the code are components for closures and attaching the footwear.This AFO is custom fabricated per the DMEPOS quality standards, Appendix C.