Section A - Overview and Background-013111.pmd

PEDORTHIC FOOTCARE ASSOCIATION

Pedorthic Footcare Association Modern Coding for Foot & Ankle DMEPOS HCPCS Codes An Analysis, Explanation, and Clarification by the PFA Coding Committee

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Initially written by the 2007-2008 PFA Coding Committee: · Mark Grundman, C. Ped. · Rick Ravel, C. Ped. · Brett Richey, C. Ped., JD, MBA · Art Smuckler, C. Ped. · Randy Stevens, C. Ped., CO · Michael Veder, C. Ped., CO, BOCO The committee would like to thank Brett Richey for his work on this manual as primary author, Dr. Paul Kesselman, and Dr. Josh White for their many valuable contributions, and Brian Lagana for his work organizing the final product. In addition, the committee would like to thank the many pedorthists, orthotists, and podiatrists who helped work on this document—and for their many valuable comments. IMPORTANT NOTE: This document is advisory in nature, and its findings have not necessarily been accepted by all third-party payors. PFA’s Pedorthic Coding Committee suggests that all practitioners/ suppliers consult with their specific payor for specific guidance. Copyright by the Pedorthic Footcare Association. All rights reserved. This publication may not be reproduced in whole or in part, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, or otherwise without written permission from the publisher. Pedorthic Footcare Association, 2025 M Street, NW, Suite 800, Washington, DC 20036 (202) 367-1145 | (202) 367-2145 - fax | [email protected] | www.pedorthics.org Page - 2

Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

Modern Coding For Foot & Ankle DMEPOS HCPCS Codes Table Of Contents: Page SECTION A: OVERVIEW & BACKGROUND ................................................................................................ 5 CHAPTER AA: MODERN CODING FOR PEDORTHIC ITEMS L3000-L3649 ............................................ 6 CHAPTER AB: GUIDE TO ABNS, COVERED/NOT COVERED, AND MEDICAL NECESSITY ............... 11 CHAPTER AC: PROPOSED CODES FOR EVALUATION AND CASTING .............................................. 19 SECTION B: L3000-L3649 SERIES OF CODES ........................................................................................ 21 CHAPTER BA: OFF THE SHELF SHOES-ADULT .................................................................................. 23 CHAPTER BB: ROCKER SOLES, ROCKER BARS, METATARSAL BARS, AND MARCH BARS ......... 33 CHAPTER BC: LIFTS AND ELEVATIONS ............................................................................................... 39 CHAPTER BD: WEDGES, FLARES, AND STABILIZERS ....................................................................... 45 CHAPTER BE: OTHER PEDORTHIC SHOE ADDITIONS AND FOOT AIDS ........................................... 53 CHAPTER BF: TRANSFER OF AN ATTACHED ORTHOSIS FROM AN EXISTING SHOE TO A NEW SHOE .................................................................................................................................... 61 CHAPTER BG: OFF THE SHELF SHOES-PEDIATRIC .......................................................................... 65 CHAPTER BH: CUSTOM AND OTS FOOT ORTHOSES ........................................................................ 69 CHAPTER BI: CUSTOM SHOES ............................................................................................................ 81 CHAPTER BJ: REPAIR CODES ............................................................................................................. 91 CHAPTER BK: OFFICIAL MEDICARE LCD FOR ORTHOPEDIC FOOTWEAR ...................................... 95 SECTION C: A5500-A5513 SERIES OF CODES ..................................................................................... 101 CHAPTER CA: OVERVIEW OF DIABETIC/NEUROPATHIC FOOTWEAR CODES .............................. 103 CHAPTER CB: OFFICIAL MEDICARE LCD FOR THERAPEUTIC SHOES FOR PERSONS WITH DIABETES .........................................................................................................113 CHAPTER CC: PCC INTERPRETATIONS, SUGGESTIONS AND GUIDANCE FOR TSD ..................... 121 CHAPTER CD: OFF THE SHELF SHOES-ADULT ................................................................................ 125 CHAPTER CE: ROCKER SOLES ......................................................................................................... 139 CHAPTER CF: LIFTS AND ELEVATIONS ............................................................................................. 147 CHAPTER CG: WEDGES, FLARES, AND STABILIZERS ..................................................................... 151 CHAPTER CH: OTHER MEDICAL GRADE SHOE ADDITIONS ............................................................ 161 CHAPTER CI: CUSTOM AND OTS FOOT ORTHOSES ........................................................................ 165 CHAPTER CJ: CUSTOM SHOES ......................................................................................................... 179 CHAPTER CK: REPAIR CODES .......................................................................................................... 187 SECTION D: AFO SERIES OF CODES ................................................................................................... 193 CHAPTER DA: INTRODUCTION TO ANKLE FOOT ORTHOSES .......................................................... 195 CHAPTER DB: OFFICIAL MEDICARE LCD FOR ANKLE-FOOT/KNEE-ANKLE-FOOT ORTHOSIS ..... 199 CHAPTER DC: PCC GUIDELINES FOR AFO CODES ..........................................................................211 SECTION E: APPENDICES ..................................................................................................................... 223 APPENDIX EA: PARTIAL GLOSSARY ................................................................................................. 225 APPENDIX EB: SUPPLIER MANUAL AND LCD LISTING .................................................................... 227 APPENDIX EC: CMS OFFICIAL LISTING OF CODES WITH ALLOWABLES ....................................... 229 APPENDIX ED: ICD-9 Codes included in Range 250.00 - 250.93 ....................................................... 233 APPENDIX EE: LIST OF COMMON PEDORTHIC ICD-9 CODES ......................................................... 235 APPENDIX EF: PFOLA Technical Standards ....................................................................................... 237 APPENDIX EG: REVISION CONTROL LIST ......................................................................................... 241 Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

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Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

SECTION A: OVERVIEW & BACKGROUND

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CHAPTER AA: MODERN CODING FOR PEDORTHIC ITEMS L3000-L3649 INTRODUCTION This document is designed to give practical and fair advice to today’s practitioners dispensing foot and ankle DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) devices. It has been developed by the PCC (PFA Coding Committee), a group formed to provide thoughtful and consistent guidance for practitioners. PCC encourages all practitioners dispensing these codes to follow this guidance (C.Ped; L. Ped; BOCPD; CO; CP; CPO; BOC (O); BOC (P); PT; ATC, DPM; DC). This document fills a huge void in the marketplace—since there has been historically little guidance given relating to the foot codes. The PCC is advisory in nature, and its findings have not specifically been authorized by any third-party payor. The practitioner is ALWAYS responsible for their own coding—including documentation and compliance with individual requirements of specific insurance companies. The PCC does publish its work and sends it to insurance companies and CMS, with the hope that it will influence the medical policy of all third-party payors. The PCC encourages practitioners to engage in thoughtful dialogue with their payors about the issues surrounding the fair use of pedorthic codes and fair reimbursement. Pedorthics has been defined several ways. At its essence, Pedorthics can be defined as “helping people in lower extremity pain, or with at-risk feet, through shoes, orthoses, foot prostheses, shoe modifications, and other footwear.” Pedorthics is practiced by many types of allied-health practitioners, including certified and/or licensed pedorthists. Though Pedorthics has enjoyed robust growth and technological development since the 1970’s, unfortunately, the L3000-L3649 codes have not kept pace with the changes and improvements in Pedorthics. Indeed, many of the codes still envision leather soled orthopedic shoes with separate heels. However, in the 21st century, very little Pedorthic work is done in this type of footwear. These Pedorthic issues are growing in importance. The Baby Boomers are the 76 million people born between 1946 and 1964. The Baby Boomers are the most important demographic trend in modern history. Feet get worse with age. As the Baby Boomers are entering their 60’s, there will be an unprecedented level of foot and ankle pain within the United States—and beneficiaries, practitioners, and third party payors need a logical, consistent, and fair coding system to deal with these issues. In addition, with the growth of the prevalence of diabetes, the codes used to administer diabetic footwear must also be harmonized with the L3000-L3649 series of codes and modern pedorthic practice. A logical robust coding system would be ME-CE (pronounced “mee-see”) (mutually exclusive, and collectively exhaustive). “Mutually exclusive” means that no two codes could be used for the same device. “Collectively exhaustive” means that the codes that exist will cover all work that is currently done in modern Pedorthics. Sadly, the current code sets are NOT ME-CE. This document tries to work within the guidelines of the current codes—providing reasoned decision rules to differentiate between codes. This document also provides suggestions for new code opportunities or new code descriptions to create a system that is up-to-date and ME-CE.1 All rule making is a form of “line drawing.” The line has to be drawn somewhere and certainly bright lines can be both over and under inclusive (include items that should not have been and exclude items that should not have been). The PCC has attempted to draw lines in such a way as to limit over and under inclusion, but acknowledges that such a task is not entirely possible. Page - 6

Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

This document is designed to expound on the most common Pedorthic devices and to provide coding guidelines to be used by practitioners. The suggestions within are designed to be ME-CE for the most common devices used today. The next chapter describes the proper use of ABNs and how to collect from the patient for non-covered codes. The PCC has several guiding principles underlying its work: 1. Code sets need to be ME-CE. 2. Code sets need to be internally consistent. 3. Third party payors want to fairly compensate practitioners for their time and materials, plus overhead and a modest profit. a. The current coding environment does not always reflect this—due primarily to the fact that no industrywide body has attempted to bring clarity to these coding issues. The PCC believes that its work will spark the necessary scrutiny and conversations to, over time, allow the L3000-L3649 series code sets to be logical and fair for all parties, and therefore allow the A5500 series to follow suit. 4. The coding is an additive coding system—so separate steps or materials should have separate codes— especially where multiple combinations are available above and beyond the “base” code. Deviations from this should only be where absolutely necessary. 5. Differences between devices will consist of differences in materials and labor, but the labor component is usually a much bigger driver to differences than material components. Therefore, distinctions between codes should have this in mind. Where the PCC has suggested a new code, we have given the code a temporary number. For suggested codes in the L3000 series, we use the syntax L3#*x, where #* is the two character chapter number (i.e. BA) and the x is the letter to differentiate the code (A is first, B is second, etc.). We will use A5#*x for codes in the A5500 series, etc. WHO SHOULD BE ABLE TO BILL THESE CODES: The PCC suggests that there should be qualified provider language for these codes. In other words, the providers of these codes should have passed some sort of exam, receive some level of relevant continuing education, and be subject to some code of ethics from a certifying board that is approved by the National Organization for Competency Assurance (NOCA—www.noca.org). This gives all payors an enforcement mechanism and gives the public a baseline of confidence. The PCC suggests the following practitioners are qualified to dispense some or all of the L3000-L3649 series: C.Ped; L. Ped; BOCPD; CO; CP; CPO; BOCO (O); BOCO (P); PT; ATC; DPM; DC. The PCC suggests noncoverage for non-qualified providers. REIMBURSEMENT LEVELS In the United States, most of these codes are cash-pay items, meaning that the UCR’s or retail prices charged by most practitioners are prices set by the marketplace (i.e. are fair and reasonable given supply and demand and the complexity of the device). There are few, if any, recorded cases of practitioners/suppliers of these items (rather than manufacturers) becoming unduly wealthy. In other words, their marketplace pricing is generally fair and is certainly not hyper-compensatory for suppliers/practitioners. The codes in this series all work in one way or another to reduce foot/ankle/leg/back pain by improving biomechanical gait and/or unloading sensitive areas. All of these devices are commonly used to TRY TO AVOID THE NEED FOR SURGERY—AND THE COSTS AND POTENTIAL COMPLICATIONS ASSOCIATED WITH SURGERY. Many are also used post-operatively—to ensure proper healing AND TO REDUCE POST-OPERATIVE COMPLICATIONS from Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

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faulty biomechanics and/or pressure buildup. As such, the savvy third-party payor pays for these devices routinely to reduce surgeries and/or complications from surgeries. It is the short-sighted third party payor that restricts use of these codes and ends up creating a market force to resort to surgery as the only tool to address pain. It is a practical reality that 1) foot/ankle/leg/back pain is a strong motivator—beneficiaries are going to seek relief, and 2) beneficiaries usually want the least invasive, least risky COVERED benefit to address their pain. If surgery is the only COVERED benefit, they are apt to choose that. If pedorthic/orthotic care and surgery are COVERED benefits, then many will choose conservative pedorthic/orthotic care first before opting for surgery. The PCC encourages insurance companies to use the PCC Acid Test: either compensate a code fairly or exclude coverage and let the marketplace decide the fair price. It is not in anyone’s long term interest to artificially underreimburse a code. All this does is 1) unduly financially penalize practitioners who are tying to provide good products and services, 2) unduly pressure practitioners to try to cut corners, or 3) force practitioners out of the insurance market. Pedorthists are not alchemists; they cannot stay in business if they are being compensated below their costs plus a reasonable profit. Included near the end of this document, in Appendix EC, is a list of allowables set by Region A DME MAC, for January 2011 for the Washington, DC area (where the PCC is based). The PCC encourages all third-party payors to at least follow these allowables. CODE SETS AND INNOVATION Any static list of codes will ALWAYS lag behind innovations in the marketplace. The PCC encourages practitioners to use the L3649 for these innovations. The PCC recognizes that most insurance companies will not cover these L3649 codes and that they will be the responsibility of the beneficiary. Again, this relies on the market mechanism to keep things in check and is in keeping with the practice of most insurance companies to not cover devices and/ or procedures that are “experimental” or “still being developed.” The practitioner’s reputation within the local medical community is on the line with any such devices/techniques, providing an additional check that such methods are reasonable. Only DPMs, DCs, and PTs (in some states) can both prescribe and supply an item. All other professionals on the PCC’s qualified provider list can only supply the item (i.e. they may NOT prescribe). Even DPMs, DCs, and PTs get the majority of their referrals from other doctors and health-care professionals. The PCC believes that in the information age, that this reliance on referrals (and separation of referral and supply for certain professions) will keep the system in check. The PCC recommends all third party payors to adopt its findings, coverages, etc. The PCC recommends that practitioners notify their third party payors, in writing, that they are complying with the PCC coding recommendations. L3000 SERIES VERSUS THE A-CODES FOR DIABETIC FOOTWEAR The CMS program that covers shoes for diabetics is often colloquially called the TSB for “Therapeutic Shoe Bill.” That was the name used to describe the program before it was passed into law in 1993, because it was a “bill”, a proposed law. Somehow the name has stuck in many quarters. The PCC recommends that all modern practitioners use the acronym TSD, for Therapeutic Shoes for Diabetics Medical Policy. The TSD A-codes are beyond the scope of this section. See Section C. DATE OF SERVICE For CMS, the date of service is when the beneficiary receives the device. That works for CMS, because Medicare beneficiaries tend to maintain their coverage permanently. The PCC recommends a different rule for private insurance, where people often do change between private insurance companies. The PCC believes that CMS should move to this method for uniformity. Page - 8

Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

For private third-party payors, the PCC recommends negotiating the Date of Service (DOS) to be the date the item was ordered from the practitioner, so long as the practitioner has delivered the device within the required number of weeks of the date the beneficiary ordered it (six weeks for custom items and three weeks for OTS items), or can prove that he/she has notified the beneficiary that the device is ready to be picked up. If the practitioner cannot meet that standard, then the DOS should be the date the item is delivered. If the practitioner can prove that the beneficiary has been notified three times in a two month period that the device is ready, and the beneficiary won’t come in to pick up the device, the practitioner can ship the device to the beneficiary’s last known address. With proof of shipment, the practitioner can bill the device using a DOS of the date the device was ordered. Medicare does have provision for billing a code when the practitioner has done the work as ordered by a beneficiary, but the beneficiary dies before the items can be picked up. Private insurances should have the same rule, assuming that the time between ordering of the device and the beneficiary’s death is a reasonable amount of time (i.e. six weeks for custom or three weeks for OTS). MODEL PEDORTHIC MEDICAL POLICY The PCC is developing a Model Medical Policy for these codes that will be the next step in the process of fully explaining these codes. This Model Medical Policy will link the HCPCS codes with their respective disease codes. This will be a policy that third party insurance companies can adopt as-is to govern the codes in this area. This document will be posted on the PFA website when ready for release. In addition, the PCC is developing a “Seal of Approval” program. Third party insurance companies can submit their Pedorthic medical policies to the PCC to see if they are close enough to the PCC’s model plan to receive our seal. Third party payors may use the seal in their marketing efforts about their plans to prospective beneficiaries. Plans that adopt the model plan would receive the seal. Plans that are significantly similar to the model plan will also receive the seal. Plans that differ greatly, or have allowables that are fundamentally low will not receive the seal. Consumers and employers selecting health care insurers are encouraged to check out the PCC’s review of each third-party payor’s plans to understand what kind of coverage they can expect relating to foot needs. (Chapter Footnotes) 1 The world is far too complex and ever-changing for code descriptions to be absolutely ME-CE. The PCC ’s goal is to account for the vast majority of what exists in the pedorthic field during the 21st century. New innovative and hybrid items will require judgment. The practitioner should make his/her own determination of the “best” coding for innovative and/or hybrid items. The goal should be to find the most closely related code, or to use the L3649 code, and document the reasons why. The PCC has a program whereby it will review situations and/or devices and provide written guidance on coding.

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Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

CHAPTER AB: GUIDE TO ABNS, COVERED/NOT COVERED, AND MEDICAL NECESSITY OVERVIEW CMS, and therefore other third-party payors, divide HCPCS codes items into Covered versus Non-Covered, and Medically Necessary versus Non Medically Necessary. If an item is Covered, and Medically Necessary, the third-party payor will pay for it. This is good for the practitioner so long as the allowable set by the third-party payor is fair. If the item fails either test, the third-party payor won’t pay—but there are special rules as to whether or not the practitioner can collect from the patient. The practitioner must follow these rules to ensure his/her ability to collect for the item dispensed. Non-Covered items do not require special paperwork if the patient is notified in writing. This means that the practitioner can collect the full retail price/UCR (usual, customary, and reasonable price) for the device from the beneficiary so long as the beneficiary has been notified in writing. If something is Covered, but potentially Not Medically Necessary—the practitioner must notify the patient in writing on a special CMS form. This special form is the ABN (Advance Beneficiary Notice of Noncoverage). It can be found at the Beneficiary Notice Initiative web page (www.cms.hhs.gov\bni). If the practitioner does not, then the CMS rules state that patient can keep the item for free—the provider cannot collect for the item. The practitioner has to use the ABN whether it is an Assigned or Non-Assigned claim. The provider should use an ABN when: ‰ The beneficiary wants a Covered item that the doctor has not prescribed. ‰ The beneficiary has already received a calendar year benefit and the beneficiary gets a second benefit in the same calendar year. ‰ The beneficiary wants a new AFO and it has not been 5 years since they got their last one (for Medicare has decided that the useful life of an AFO is 5 years). ‰ The beneficiary wants a deluxe upgrade or a deluxe cosmetic feature—or something for their convenience or comfort (rather than medical necessity) that CMS is not going to cover. ‰ Historically, CMS discouraged the “routine” use of ABNs. An ABN had to be used to disclose issues of Medical Necessity and a Notice Of Exclusions From Medicare Benefits (NEMB) for issues of Non-Coverage. Since March, 2008, CMS allows the use of ABNs for both, and is phasing out the NEMB. NON COVERED VS NOT MEDICALLY NECESSARY NON COVERED ITEMS For any item to be Covered by CMS, it must: 1) be eligible for a defined CMS benefit category; 2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member; 3) meet all other applicable CMS statutory and regulatory requirements. For example, CMS’s policy on shoes indicates that they will pay for OTS shoes under two circumstances: 1) TSD, and 2) when the shoe is attached to a brace. For a diabetic beneficiary, OTS shoes will be Covered as long as the beneficiary meets the requirements described in the CMS policy as eligible for shoes, the beneficiary has been Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

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diagnosed as diabetic (because diabetes is a required diagnosis for TSD), and the practitioner has collected the appropriate paperwork and has followed the rules of the TSD. For a non-diabetic beneficiary without a brace, the shoes would be considered as Non-Covered because the beneficiary’s condition does not meet the coverage criteria as it is written in the CMS policy for the shoes. Other examples of Non-Covered items would be when: · The beneficiary receives more pairs of inserts for TSD than are allowed, either: o The beneficiary wanted lots of inserts because the beneficiary is hard on inserts (i.e. greater than 3 pair of OTS or 2 additional pair of custom shoe inserts). o The beneficiary needed a full spectrum of inserts AND shoe modifications—rather than substituting shoe modifications for inserts. ƒ For consistency, the PCC recommends that the inserts be counted first towards the beneficiary’s quota, followed by shoe modifications. · The beneficiary receives additional features to a molded shoe above and beyond the base shoe and inserts. · The beneficiary receives a shoe modification as part of TSD that was not related to diabetes—for example a set of hook-and-loop straps that was for arthritis in the hands. The patient is responsible for all Non-Covered charges. The practitioner’s beneficiary forms should clearly identify all Non-Covered items (see Sample Form attached). The patient, by signing the form, acknowledges that they are financially responsible for the Non-Covered items. NOT MEDICALLY NECESSARY ITEMS Items that are deemed Not Medically Necessary by CMS include: 1) items which are not ordered by a physician or other qualified practitioner; 2) items which are the same or similar to covered items that the beneficiary is already using; 3) items that are deemed not reasonable and necessary for the given condition (for instance—a toe filler if no amputation exists). For example, while custom shoes for a diabetic person are Medically Necessary, “special” features on the shoes will be considered Not Medically Necessary, such as a special sole or hook-and-loop closure added, unless the special feature is clearly necessary to aid in the patient’s diabetes treatment. In order for CMS to accept special features as Medically Necessary, the diagnosis must support the need for the feature and the physician’s order must specifically state the item. If the order only indicates diabetic shoes and the practitioner provide inserts to the patient as well, the inserts will be denied as Not Medically Necessary even though the inserts would be supported by the diagnosis because the physician did not indicate that the patient needed these on the Rx. If the patient has had an AFO in the last 5 years (paid for by CMS) and the practitioner provides a second AFO, the second AFO will be deemed Not Medically Necessary because CMS believes that the life of an AFO is 5 years (to avoid this, the practitioner would either have to document that the old AFO is lost/destroyed or that there has been a change in medical condition necessitating the new AFO). An ABN must be used for patients that are receiving items that are not expected to be paid because they do not fit the definition of being Medically Necessary. The patient should pay for any items that are considered to be Not Medically Necessary. An ABN may now also be used for items that are Non-Covered by CMS. CMS specifically prohibits the use of routine ABNs (i.e. having every beneficiary sign an ABN “just in case”). ABNs can be liberally used, but not Page - 12

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rampantly used. The PCC recommends that practitioners read the rules surrounding ABNs and judiciously use the ABN so as not to invalidate it. Here is the decision matrix:

MEDICALLY NECESSARY

COVERED

NOT COVERED

PCC Box 1

PCC Box 2

Everything is billable and should be PATIENT PAYS paid—if the practitioner has his/her Generally don’t bill. If the beneficiary demands it, paperwork, file with the KX modifier the practitioner may bill with a GY modifier (automatic denial). Don’t have to use an ABN, but can PCC Box 3

NOT MEDICALLY NECESSARY Must have Patient sign an ABN (NMN) and file with GA modifier.

PCC Box 4 PATIENT PAYS Don’t bill. If the patient demands it, politely refuse and encourage them to contact their third-party payor.

If not, then Patient gets to keep the item(s) for free and the practitioner Don’t use an ABN loses.

Examples: PCC Box 2 ‰ For instance—beneficiaries with Rheumatoid Arthritis in their feet NEED special shoes and inserts, but CMS has never decided to cover them. They have only decided to cover them for beneficiaries with diabetes (who also meet certain conditions). ‰ THE TSD ALLOWS AN A5500 AND 6 UNITS OF INSERTS OR MODIFICATIONS (OR AN A5501 AND 4 ADDITIONAL UNITS OF INSERTS OR MODIFICATIONS). IF THE PRACTITIONER HAS AN RX FOR MORE UNITS THAN ARE COVERED, THE EXCESS UNITS ARE CONSIDERED MEDICALLY NECESSARY, BUT NOT COVERED—SO THE PRACTITIONER CAN PROVIDE THEM, AND COLLECT THE FULL RETAIL/UCR FOR THEM FROM THE PATIENT. The proposed billing form shows these items clearly as Non-Covered and the full financial responsibility of the patient. PCC Box 3 ‰ The Rx just says “shoes” and the practitioner provides “shoes and inserts”—the inserts are considered NMN since they were not on the Rx. ‰ The beneficiary has already gotten their TSD benefit for the year (CMS assumes only one TSD benefit per year is Medically Necessary). The practitioner dispenses a second set of benefits to the beneficiary for the same calendar year. The second set is considered Not Medically Necessary (NMN). ‰ There is a feature of a covered item that is considered deluxe, or NMN. For instance, the patient pays to upgrade the leather on a shoe to a purple python so that the shoe can match the patient’s clothing. The shoe may be medically necessary, but the incremental price to upgrade the leather is not. Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

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The PCC understands that some private insurance contracts have provisions that alter the definition of Covered and Non-Covered and changes the obligations of the supplier. These changes can have the effect of requiring the supplier to provide the device while eliminating the ability of the supplier to collect from either the insurance company or the patient. The PCC strongly urges all suppliers to carefully read the Coverage provisions of their contracts and to be very cautious of the effect of these provisions. For the most up-to-date rules on using ABNs and the GA modifier (and it’s tandem modifiers) please consult the CMS website. The current form was released on March 3, 2008. Some key features of the new form are that it: · Has a new official title, the “Advance Beneficiary Notice of Noncoverage (ABN)”, in order to more clearly convey the purpose of the notice; · Replaces the ABN-G and ABN-L; · May also be used for voluntary notifications, in place of the Notice of Exclusion from Medicare Benefits (NEMB); · Has a mandatory field for cost estimates of the items/services at issue; and · Includes a new beneficiary option, under which an individual may choose to receive an item/service, and pay for it out-of-pocket, rather than have a claim submitted to Medicare. Note: the predecessor forms ABN-G and ABN-L are no longer valid as of March 1, 2009.

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Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

FAQs: “ABNs and Upgraded DMEPOS” ABN = Advance Beneficiary Notice of Noncoverage (form CMS-R-131) DMEPOS = Durable medical equipment, prosthetics, orthotics, and supplies. A. GENERAL QUESTIONS ABOUT UPGRADES Question A1: What is a DMEPOS upgrade using an ABN? Answer A1: A DMEPOS upgrade is the furnishing of an item that includes an “excess component,” e.g., deluxe or aesthetic features of equipment. “Excess component” means an item, feature, and/or the extent of, number of, duration of, or expense for an item or feature, which is in addition to, or is more extensive and/or more expensive than, the item which is medically necessary under Medicare coverage requirements. When upgraded DMEPOS is to be furnished and the supplier expects a Medicare reduction in payment based on a medical necessity partial denial of coverage for additional expenses attributable to the upgrade, an ABN should first be delivered to the beneficiary and the signature of the beneficiary, agreeing to be personally and fully responsible for payment for those additional expenses, should be obtained. Using an ABN to upgrade DMEPOS is clearly for features or options that are above and beyond medical necessity. Using ABNs to attempt to resolve coding and pricing issues is inappropriate. Question A2: May an ABN be used to charge a beneficiary an additional amount for an item merely on the basis that the item is “higher quality”? Answer A2: ABN’s may not be used to charge beneficiaries more for “higher quality” items when there is not a distinguishable excess component of the items. Such charge increases on the basis of purported premium quality items would constitute circumvention of payment limits and applicable Medicare charge limits. An excess component, with respect to items that are more expensive, refers to increased charges attributable to furnishing something that is clearly more extensive, that is, more in number, more frequent, for a longer period of time, or with added features. A deluxe or aesthetic feature of an upgraded item is an excess component. It does not suffice merely to claim that an item is “better” or “higher quality.” Question A3: As of what date may a supplier use an ABN to charge a beneficiary an additional amount for an upgraded item? What ABN form must be used? Answer A3: ABNs may be used to furnish upgrades on or after March 3, 2008, the date of the approval of the new ABN form (CMS-R-131) by OMB. The OMB has also released a version in Spanish. Both forms are available online at www.cms.hhs.gov\bni. Question A4: May an ABN be used to substitute a dissimilar item for the item that the attending physician ordered for the beneficiary and to obtain Medicare payment for the ordered item? Answer A4: No. ABNs may not be used for substitution of a dissimilar item with Medicare payment for the ordered item. A “dissimilar item” is a substantially different item that is not both medically appropriate for the beneficiary’s medical condition and consistent with the physician’s original order. For example, ABNs may not be used for substitution of a wheelchair when a cane was prescribed, nor for a hospital bed when a wheelchair was prescribed, because canes, wheelchairs, and hospital beds are dissimilar items, substantially different from one another. On the other hand, ABNs may be used for substitution of similar items, e.g., substitution of a wheelchair with additional Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

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features when a wheelchair without those features was prescribed, and substitution of a hospital bed with additional features when a hospital bed without those features was prescribed. If a beneficiary wants substitution of a dissimilar item, an ABN to the beneficiary must specify that the full cost of the dissimilar item furnished will be at the beneficiary’s own expense. Question A5: What is the supplier’s responsibility when using an ABN to allow a beneficiary to upgrade from an item which is medically necessary to an item which is not at all medically necessary (e.g., from a manual wheelchair to a power wheelchair when the ordering physician does not want the beneficiary to use a power wheelchair)? Answer A5: In the special case where a beneficiary wants to upgrade to an item and the supplier is aware that the ordering physician wants the beneficiary to use the item ordered for clinical reasons (e.g., the physician would consider the upgraded item to be unsafe for that beneficiary), the entire upgraded item would not be medically necessary and Medicare would make no payment for it. If a supplier has such a case and the beneficiary signs an ABN which specifies that the full cost of the upgraded item will be at the beneficiary’s own expense, the supplier should advise the beneficiary to contact his/her physician to notify the physician that s/he upgraded the equipment. In cases where there is no such medical objection from the physician, a beneficiary could upgrade from a manual wheelchair to a power wheelchair, being made responsible to pay the difference in cost between the two by an ABN. Question A6: What must a supplier specify in the “Items or Services:” and “Reason Medicare May Not Pay:” boxes of form CMS-R-131, and enter in the “Estimated Cost:” blank of form CMS-R-131, in order to properly charge a beneficiary an additional amount for an upgraded item? Answer A6: The supplier must specify in the “Items or Services:” box the excess component(s) for which denial is expected. NOTE: It is the upgrade features that are expected to be denied, the excess components, that are the subject of the ABN, not the standard item for which payment is expected. The supplier should not specify the entire piece of equipment in the “Items or Services:” box when using the ABN for an upgrade. Likewise, the supplier must specify in the “Reason Medicare May Not Pay:” box the reason that Medicare is expected to deny payment for the specified excess components related to the upgrade. The supplier should enter in the “Estimated Cost:” blank of the ABN the extra expense for the specified excess components, over and above the Medicare allowable amount for the standard item, not the total cost of the upgraded item. It is this extra expense for which a beneficiary who signs an ABN may agree to be responsible for payment if Medicare denies payment. EXAMPLE: A patient’s physician ordered a manual wheelchair but the patient wants to upgrade to a motorized wheelchair. The supplier should specify in the “Items or Services:” box the excess component - in this case, that is the motorized feature. The supplier should not specify the entire item (e.g., “motorized wheelchair”). The supplier should specify in the “Reason Medicare May Not Pay:” box the reason that Medicare is expected to deny payment for the motorized feature, for example, “Your condition does not support the need for the motorized feature of this equipment.” The supplier should enter the cost estimate for the amount attributable to the motorized feature, over and above the Medicare allowable amount for the manual wheelchair. B. WITHIN-A-CODE UPGRADES Question B1: A piece of equipment has an upgrade which is a particular feature that the supplier believes to be an excess component. The beneficiary’s physician’s order for the piece of equipment did specify this particular feature. May a beneficiary be charged an additional amount for equipment with this particular feature by executing an ABN? Page - 16

Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

Answer B1: Yes. Even though the physician ordered equipment with that feature, a supplier which believes that the feature is an excess component for which Medicare payment may be denied may give an ABN for that feature. Because a partial denial of Medicare payment for the piece of equipment with that feature is expected, an ABN may be used to charge the beneficiary an additional amount for that feature. Where a supplier does not have a genuine reason to expect Medicare denial, physician-ordered features should be provided without additional charge. Question B2: A piece of equipment has an upgrade which is a particular feature that is an excess component. The beneficiary’s physician’s order for the piece of equipment did not specify this particular feature. May a beneficiary be charged an additional amount for equipment with that particular feature by executing an ABN? Answer B2: Yes. Because the feature is an excess component which the physician did not order, a beneficiary who is willing to personally purchase that feature may do so by signing an ABN which specifies that feature, the reason for expecting denial by Medicare (e.g., “Your condition does not support the need for the special features of this equipment” or “Medicare will not pay for a [specify the feature] on this piece of equipment for your condition”), and the extra cost to the beneficiary for that feature. C. CODE-TO-CODE UPGRADES Question C1: A beneficiary’s physician ordered a particular piece of equipment but the beneficiary wishes to obtain an upgraded piece of similar equipment with an additional feature (or features), which is defined by a different HCPCS code than the ordered equipment. May a beneficiary be charged an additional amount for the upgraded equipment by executing an ABN? Answer C1: Yes. The similar, but upgraded, equipment has an additional feature that is not medically necessary for the individual because the physician did not order equipment with that feature. That feature, therefore, is an excess component for which no additional payment may be made by Medicare under the fee schedule for the particular piece of equipment that the physician ordered. A beneficiary who is willing to personally purchase that feature may do so by signing an ABN which specifies that feature, the reason for expecting denial by Medicare, and the extra cost to the beneficiary for that feature. Question C2: A beneficiary’s physician ordered a particular piece of equipment but the beneficiary wishes to obtain a dissimilar piece of equipment, which is defined by a different HCPCS code, which is more expensive than the ordered equipment. (For example, the physician ordered a walker, but the beneficiary wants to purchase a wheelchair.) May a beneficiary be charged an additional amount for the dissimilar equipment by executing an ABN which specified the difference in cost between the items? Answer C2: No. ABNs may not be used for substitution of a dissimilar item. In the example given, Medicare would pay nothing towards the wheelchair. If the supplier obtained the beneficiary’s signature on an ABN which specified that Medicare would not pay at all for the wheelchair and specified the full cost of the wheelchair to the beneficiary, the beneficiary could obtain the wheelchair at his/her own expense.

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PCC Beneficiary Notice Form: Practitioner/Facility Name:

Date:

Beneficiary Name: Primary Third Party Payor: Secondary Third Party Payor: COVERED AND MEDICALLY NECESSARY: The following items are covered by your primary payor and are considered “medically necessary” (i.e. they were ordered by your doctor and supported by the necessary medical documentation for your condition): These items will be billed to your third-party payor(s) and it is expected that your third-party payor(s) will pay towards these items, in accordance with their rules.

HCPCS CODE

UNITS

MODIFIER LT RT KX LT RT KX LT RT KX LT RT KX LT RT KX

ICD-9

UCR $ $ $ $ $

___ ___ ___ ___ ___ Total:

NOT COVERED, YET MEDICALLY NECESSARY: The following items are NOT covered by your primary payor, but are still considered “medically necessary” (i.e. they were ordered by your doctor and supported by the necessary medical documentation for your condition): These items will NOT be billed to your third-party payor(s). You, the beneficiary, are responsible for these items.

HCPCS CODE

UNITS

MODIFIER LT RT GY LT RT GY LT RT GY LT RT GY LT RT GY

ICD-9

UCR $ $ $ $ $

___ ___ ___ ___ ___ Total:

COVERED, YET NOT MEDICALLY NECESSARY (NMN): The following items are covered by your primary payor, yet are NOT considered “medically necessary” (i.e. they were NOT ordered by your doctor or are NOT supported by the necessary medical documentation for your condition): These items will NOT be billed to your third-party payor(s). You, the beneficiary, are responsible for these items. You must also sign a separate ABN for these items.

HCPCS CODE

UNITS

MODIFIER LT RT GA ___ LT RT GA ___ LT RT GA ___

ICD-9

UCR $ $ $

Total: Note: It is against insurance company policy and our policy to bill for items that are NMN and Not Covered. Beneficiary Signature: _____________________________________________________________________________ Page - 18

Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

CHAPTER AC: PROPOSED CODES FOR EVALUATION AND CASTING The pedorthic care cycle involves these time steps: · Initial evaluation and assessment · Treatment plan determination and documentation · Casting/Measuring · Ordering/Fabricating · Fitting · Adjusting · Follow up. The original design of the HCPCS system was to have the reimbursement for the code include the time for the practitioner for evaluation, fabrication, fitting, and follow-up as well as the materials cost of the device. This system has come under strain in recent years. Since the evolution of these codes in the 1970’s, all pedorthists have undergone the following changes: 1) increased assessment times based on increases of the clinical requirements of the profession; 2) increased documentation requirements do to legal concerns; 3) additional administrative and documentation requirements due to billing issues, and 4) significantly increased cost in the newest casting methods and the costs to ship/transmit casts/impressions. The reimbursement levels for devices today are generally adequate to cover the “variable cost” time involved in the final four bullets listed above, but not for the “fixed cost” time involved in the first three. In addition, many times the pedorthist will do a doctor’s prescribed evaluation and assessment, yet the patient may not need a new device and/or the patient may decide for their own reasons to forgo getting a device after the practitioner has spent the time to develop the evaluate and asses and develop the treatment plan. Since the pedorthist worked with the patient, the pedorthist is required to document his or her work and create a file. When this happens, the pedorthist gets no reimbursement for their valuable time. Many times a pedorthist may be asked to give a second opinion on a case, to provide a stand-alone value-added service such as gait analysis or plantar pressure mapping, or may be asked to evaluate a patient for the benefit of a workman’s compensation insurance company’s assessment and/or long term treatment plan. All of these examples involve the pedorthist to spend time, but do not involve the dispensing of an item. The PCC wants to make it clear to pedorthists that they can, and should, charge for their time spent in these ways. In addition, as doctors and physical therapists have begun to supply more and more of these codes, a horizontal inequality has developed whereby some practitioners can bill for their time, yet others cannot. There is already a precedent within some HCPCS codes for a pedorthist to bill for time (i.e. the repair codes and the brace transfer codes). The PCC believes that the time has come to provide a mechanism for pedorthists to be adequately compensated for their time initial “fixed cost” time in a way that is clear, direct and consistent with other practitioners. As such, the PCC suggests the following new codes (see page 20).

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Old Description

PCC/New Description

Explanation

Currently, no such code exists

L3ACA Pedorthic AssessmentInitial Visit. Includes initial assessment and documentation of pedorthic treatment plan. Excludes casting for custom device.

This code is the initial pedorthic assessment code for time spent evaluating the patient and developing a treatment plan. It does not include casting. This is to cover the two top bullets at the beginning of this page.

Currently, no such code exists

L3ACB Pedorthic casting for custom item, includes casting supplies, foot only impressions, any type, per foot.

This code is for the casting of the feet only for a custom device. This could be in foam or plaster or by a digital methodology. It includes the casting materials and shipping/ transmitting the casts.

Currently, no such code exists

L3ACC Pedorthic casting for custom item, includes casting supplies, foot and ankle impressions, any type, per foot.

This code is for the casting of the feet and ankle only for a custom device. This could be wrap or bivalve casts or by a digital methodology. It includes the casting materials and shipping/transmitting the casts.

EVALUATION AND CASTING CODES

As a matter of public policy, the PCC does not suggest incremental codes ever be developed or allowed for time spent in follow-up. We believe that the reimbursement for the follow up time should always be part of the underlying device code. This aligns the interests of the practitioner and patient—to “get it right” quickly.

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Modern Coding for Foot and Ankle DMEPOS HCPCS Codes