OAR 410-122-0662: Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover some ankle-foot orthotics (AFOs) and knee-ankle-foot Orthotics (KAFOs) and related services for a covered condition, for this episode, when the covered device has not been billed to the Division with a Current Procedure Terminology (CPT) code, Healthcare Common Procedure Coding System (HCPCS) code or diagnosis code by any other healthcare provider, and in addition specifically for: (a) AFOs not used during ambulation: A static AFO (L4396) may be covered when (A)-(E) are met: (A) The client has a plantar flexion contracture of the ankle (Internal Classification of Diseases (ICD)-10 diagnosis code M24.571, M24.572) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); (B) There is a reasonable expectation of the ability to correct the contracture; (C) The contracture is interfering or expected to interfere significantly with the client’s functional abilities; (D) The static AFO is used as a component of a therapy program that includes active stretching of the involved muscles and/or tendons; (E) The pre-treatment passive range of motion is measured with a goniometer and an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home) is documented in the client’s treatment plan; (b) AFOs and KAFOs used during ambulation: (A) AFOs described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360 and L4386 with weakness or deformity of the foot and ankle requiring stabilization fro medical reasons and with potential to benefit functionally; (B) KAFOs described by codes L2000-L2038, L2126-L2136 and L4370 when conditions of coverage are met for an AFO and additional knee stability is required: (C) AFOs and KAFOs that are molded-to-patient model, or custom-fabricated when basic coverage criteria for an AFO or KAFO are met and one of the following criteria is met: (i) The client could not be fit with a prefabricated AFO; (ii) The condition necessitating the orthotic is expected to be permanent or of longstanding duration (more than six months); (iii) There is a need to control the knee, ankle or foot in more than one plane; (iv) The client has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; (v) The client has a healing fracture that lacks normal anatomical integrity or anthropometric proportions; (c) No more than one replacement interface (L4392) may be covered every six months for a covered static AFO; (d) Evaluation of the client, measurement and/or casting and fitting of the orthotic are included in the allowance for the orthotic; (e) Repairs/Replacement: (A) Repairs to a covered orthotic due to wear or to accidental damage when necessary to make the orthotic functional. If the expense for repairs exceeds the estimated expense of providing another entire orthot, no payment will be made for the amount in excess; (B) Replacement of a complete orthotic or component of an orthotic due to loss, significant change in the client’s condition or irreparable accidental damage if the device is still medically appropriate and conditions of coverage are met; (C) L4205 (Repair of orthotic device, labor component, per 15 minutes): (i) May only bill for the actual time involved in the repair of an orthotic; (ii) May not use this code for any labor involved in the evaluation, fabrication or fitting of a new or full replacement orthotic; (iii) Use for the labor component of repair of a previously provided orthotic; (D) Labor Allowance: (i) Included in the replacement of an orthotic component coded with a specific L code; (ii) Not included in the replacement of an orthotic component coded with L4210; (E) Replacement items with specific HCPCS codes: (i) Use L4392 and L4394 for replacement soft interfaces used with ankle contracture orthotics or foot drop splints; (ii) Use L2999 (Lower extremity orthotics, not otherwise specified) for replacement components that do not have a specific HCPCS code; (iii) Addition codes L4002 — L4130, L4392 for replacement components are not payable at initial issue of a base orthotic; (f) The codes specified in this rule may be covered for a client residing in a nursing facility; (g) Quantities of supplies greater than those described in the policy as the usual maximum amounts only when supported by documentation clearly and maximum amounts only when supported by documentation clearly and specifically explaining the medical appropriateness of the excess quantities. (2) Exclusions: The following services are not covered; (a) A static AFO and replacement interface for: (A) A fixed contracture; or (B) A foot drop without an ankle flexion contracture; (C) When used solely for the prevention or treatment of a heel pressure ulcer; (b) A component of a static AFO that is used to address positioning of the knee or hip; (c) A foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394) for a non-ambulatory client when used solely for the prevention or treatment of a pressure ulcer; (d) An AFO or KAFO and any related addition for an ambulatory client when used solely for treatment of edema and/or prevention or treatment of a pressure ulcer; (e) Walking boots used primarily to relieve pressure, especially on the sole of the foot or used solely for the prevention or treatment of a pressure ulcer; (f) Elastic support garments (L1901); (g) Socks (L2840, L2850) used in conjunction with orthotics; (h) Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out; (i) A foot pressure off-loading/supportive device (A9283); (j) L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) if either the coverage criteria for the base orthotic is not met or the specific addition is not medically appropriate. (3) Coding Guidelines: (a) A prefabricated orthotic is one that is manufactured in quantity without a specific client in mind. A prefabricated orthotic may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific client (i.e., custom fitted). An orthotic that is assembled from prefabricated components is considered prefabricated. Any orthotic that does not meet the definition of a custom-fabricated orthotic is considered prefabricated; (b) A custom-fabricated orthotic is individually made for a specific client starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as cutting, bending, molding, sewing, etc. It may involve some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item; (c) A molded-to-patient model orthotic is a particular type of custom-fabricated orthotic in that an impression of the specific body part is made (by means of a plaster cast, computer-aided design and computer-aided manufacturing (CAD-CAM) technology, etc.). This impression is used to make a positive model (of plaster or other material) of the body part. The orthotic is then molded on this positive model; (d) Ankle-foot orthotics 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 that are shoe inserts that do not extend above the ankle. A nonambulatory ankle-foot orthotic may be either an ankle contracture splint, night splint or a foot drop splint; (e) A static AFO (L4396) is a prefabricated ankle-foot orthotic that has all of the following characteristics: (A) Designed to accommodate an ankle with a plantar flexion contracture up to 45°; (B) Applies a dorsiflexion force to the ankle; (C) Used by a client who is minimally ambulatory or nonambulatory; (D) Has a soft interface; (f) A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthotic that has all of the following characteristics: (A) Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); (B) Not designed to accommodate an ankle with a plantar flexion contracture; (C) Used by a client who is nonambulatory; (D) Has a soft interface. (4) HCPCS Modifiers: (a) EY — No physician or other licensed health care provider order for this item or service; (b) GY — Item or service statutorily excluded or does not meet the definition of any Medicare benefit: (A) If an AFO or a KAFO is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and any related additional code; (B) If a walking boot (L4360, L4386), static AFO (L4396) or foot drop splint/recumbent positioning device (L4398) is used solely for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and to the code for the replacement liner (L4392, L4394); (C) When the GY modifier is added to a code there must be a short narrative statement indicating why the GY modifier was used — e.g., “used to prevent pressure ulcer” or “used to treat pressure ulcer” or “used to treat edema”. This statement must be entered in the narrative field of an electronic claim or attached to a hard copy claim; (c) KX — Requirements specified in the medical policy have been met. The provider must add a KX modifier to the AFO/KAFO base and additional codes only if all the coverage criteria of this policy have been met and evidence of such is retained in the provider’s files; (d) LT — Left Side; RT — Right Side: (A) The right (RT) and left (LT) modifiers must be used with orthotic base codes, additions and replacement parts; (B) When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using the LTRT modifiers and 2 units of service. (5) Documentation Requirements: (a) L2999 is the only code in this rule that requires prior authorization (PA): For a PA request, submit documentation for review that supports conditions of coverage as specified in this rule are met, including the plan of care, if applicable; (b) For services that do not require PA: Documentation from the medical record that supports conditions of coverage as specified in this rule are met must be kept on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider; (c) Prior to billing for each new or full replacement item, the DMEPOS provider must first have received a completed written, signed and dated practitioner’s order that includes: (A) The treating diagnosis code that justifies the need for the orthotic device; (B) Detailed description of the item including all options or additional features; (C) The unique features of the base code plus every addition that will be billed on a separate claim line; (d) For custom-fabricated orthotics, documentation must support the medical appropriateness of that type device rather than a prefabricated orthotic; (e) For L2999: (A) The request for PA must include the following information: (i) A narrative description of the item (for custom fabricated items); or (ii) The manufacturer’s name and model name/number (for pre-fabricated items); and (iii) Justification of medical appropriateness for the item; (iv) For replacement components, a HCPCS code or the manufacturer’s name and model name/number of the base orthotic; (v) The manufacturer’s name and model name/number must be entered in the narrative field of an electronic claim; (f) Repair of orthotic devices: (A) A practitioner’s order is not required; (B) A detailed description of the reason for the repair, part that is being repaired or replaced must be on file with the DMEPOS provider; (C) The following information must be entered in the narrative field of an electronic claim: (i) L4210 must include a description of each item that is billed; (ii) L4205 must include an explanation of what is being repaired; (D) All codes for repairs of orthotics billed with the same date of service must be submitted on the same claim; (g) The provider must include the ICD-10 diagnosis code for the underlying condition on the claim for a static AFO (L4396) or replacement interface material (L4392); (h) All codes for orthotics billed with the same date of service must be submitted on the same claim; (i) When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, there must be documentation in the client’s medical record supporting the medical appropriateness for the higher utilization; (j) The client’s medical record must support the medical appropriateness for items and all additions billed to the Division and this documentation must be made available to the Division on request. (6) Table 122-0662 [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]