Transcript Therapeutically Appropriate and Least Expensive How to
Dx. Specific DME Protocols MPMA Summer Meeting
Hal Ornstein, DPM, FACFAS Chairman, AAPPM 18 Years in Private Practice President of the Jeff Frederick Fan Club
REASONS TO FOLLOW THESE PROTOCOLS
• • • • • • • •
Improved outcomes Easy to follow Medico-legal security Improved patient compliance Improved patient satisfaction Patient convenience Ease of inventorying Consistent with standards of care
Documentation Summary, Chart
Prescription or order Documentation of Therapeutic Necessity Signed Certification of Patient Receipt Chart Notes of Dispense Invoice
Documentation Summary, Office
Complaint Resolution Policy, Forms, Log Supplier Standards Warrantee Info Posted hours
L2999 L1902 L1906 L4386 L4396 L4360 L1971 L4350 L1932 L1951 DME Codes Non covered AFO gauntlet style AFO multiligamentous AFO non-pneumatic walking AFO plantar fascia night splint AFO pneumatic below knee AFO with ankle joint AFO ankle control orthosis AFO dynamic AFO spiral, plastic, other
DME Codes L1940, L2210, L2330, L2820
Arizona AFO, dynamic assist L1970, L2210, L2820
Richie AFO, dynamic assist L1940, L2330, L2820
Arizona AFO, standard L1970, L2820b
Richie AFO L1940, L2330, L2820
Arizona AFO, tall L1960, L2340, L2820
Arizona AFO extended A5501, A5506, A5503
Custom molded shoes with rocker bottoms and offset heels L1940, L2330, L2820, A5501, A5506, A5503
Custom molded shoe with Arizona Standard AFO
Plantar Fasciitis
728.71
718.47 Plantar fascial fibromatosis Plantarflexion contracture of ankle
Plantar fasciitis: Initial Visit Aircast Airheel Suggested Code: Patient Pays L2999 PowerStep Insert Suggested Code: Patient Pays L2999
Plantar fasciitis: Subsequent Visit
Mild
Ossur Formfit Ossur Exoform Ossur Airform Night Splint, posterior or dorsal Suggested Code: DMEPOS Fee Ceiling: L4396 $180
Plantar fasciitis: Subsequent Visit
Severe
Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Posterior Tibialis Tendonitis
726.72
905.8 Tibialis tendonitis Late effect of tendon injury, sprain, strain
Posterior Tibialis Tendonitis, Mild: Initial Visit PowerStep Insert Suggested Code: Patient Pays L2999 Aircast Airlift PTTD Suggested Code: DMEPOS Fee Ceiling: L1906 $135
Posterior Tibialis Tendonitis, Moderate : Initial Visit Donjoy Velocity ES Suggested Code: DMEPOS Fee Ceiling: L1971 $505
Posterior Tibial Tendonitis: Severe, Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Posterior Tibialis Strain, Moderate : Subsequent Visit Ossur Formfit Ossur Airform Ossur Exoform Night Splint, posterior or dorsal Suggested Code: DMEPOS Fee Ceiling: L4396 $180
Posterior Tibialis, Rupture, Stage 3
727.68
728.4
Rupture, tendon of foot and ankle, non traumatic Laxity of ligament 734 Flat foot, acquired
Posterior Tibialis Strain, Rupture, Stage 3: Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Posterior Tibialis Strain, Rupture, Stage 3:
Subsequent Visit, if getting better
Less Severe More Severe
Aircast Airlift PTTD Suggested Code: DMEPOS Fee Ceiling: L1906 $135 Donjoy Velocity ES Suggested Code: DMEPOS Fee Ceiling: L1971 $505
Posterior Tibialis Strain, Rupture, Stage 3: Subsequent Visit, if getting worse Suggested Code: DMEPOS Fee Ceiling: Arizona AFO Suggested Code: DMEPOS Fee Ceiling: L1940, L2330, L2820 $1099 Richie AFO L1970, L2820 $901
Ankle Sprain, Grade 1
845.02
Sprain and strain of ankle and foot, calcaneofibular 845.00
Sprain and strain of ankle and foot, unspecified site 729.5
719.07 Pain in limb Unspecified disorder of ankle and foot
Ankle Sprain, Grade 1
: Initial Visit
Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135
Ankle Sprain, Grade 2, 3
729.5
719.07 845.02
845.01
824.2
824.6
Ankle pain and support Effusion of joint, ankle, foot Sprain and strain of ankle and foot, calcaneofibular Sprain and strain of ankle and foot, deltoid ligament Ankle fracture, lateral malleolus only Ankle fracture, trimalleolar
Ankle Sprain, Grade 2, 3: Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Ankle Sprain, Grade 2, 3:
Follow up visit, 2 - 6 weeks
Healing Well Delayed Healing
Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135 Donjoy Velocity ES Suggested Code: DMEPOS Fee Ceiling: L1971 $505
Pediatric Fracture
729.5
719.07 845.02
845.01
824.2
824.6
Ankle pain and support Unspecified disorder of ankle and foot Sprain and strain of ankle and foot, calcaneofibular Sprain and strain of ankle and foot, deltoid ligament Ankle fracture, lateral malleolus only Ankle fracture, trimalleolar
Pediatric Fracture: Initial Visit
Aircast SP Walker Aircast XP Walker Pneumatic Walker, Pediatric Size Suggested Code: DMEPOS Fee Ceiling: L4360 $312
Pediatric Fracture:
Follow up visit, 7 - 9 weeks
Aircast Air-Stirrup, pediatric size Suggested Code: DMEPOS Fee Ceiling: L4350 $100
Ankle Instability
845.02 Sprain and strain of ankle and foot, calcaneofibular 845.00
Sprain and strain of ankle and foot, unspecified
Ankle Instability: Initial Visit Mild Moderate Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135 Donjoy Velocity ES Suggested Code: DMEPOS Fee Ceiling: L1971 $505
Tarsal Tunnel Syndrome
355.5
719.47 Tarsal tunnel syndrome Pain in joint, ankle, foot
Tarsal Tunnel Syndrome
:
Initial Visit Mild Moderate Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135 Donjoy Velocity ES Suggested Code: DMEPOS Fee Ceiling: L1971 $505
Tarsal Tunnel Syndrome, severe
:
Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Peroneal Tendonitis
????
?????
Peroneal Tendonitis
:
Initial Visit Mild, Moderate Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135
Peroneal Tendonitis, severe
:
Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Peroneal Tendonitis
:
Subsequent Visit Severe Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135
Sinus Tarsi Syndrome
726.79
719.47 Enthesopathy of ankle and tarsus, other Pain in joint, ankle, foot
Sinus Tarsi Syndrome : Initial Visit Mild Moderate Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135 Donjoy Velocity ES Suggested Code: DMEPOS Fee Ceiling: L1971 $505
Sinus Tarsi Syndrome
:
Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Severe Sinus Tarsi Syndrome : Subsequent Visit Ossur Gameday Suggested Code: DMEPOS Fee Ceiling: L1906 $135
Drop Foot
736.79
438.20 719.97
356.1
disease 340 138 728.85
Acquired deformity of foot and ankle Hemiplegia Joint derangement, ankle and foot Peroneal muscle atrophy, Charcot Marie Tooth Multiple sclerosis Poliomyelitis, late effects Spasm of muscle
Flaccid Drop Foot
: Initial Visit Euro International Peromax Suggested Code: DMEPOS Fee Ceiling: L1932 $962 Ossur Dynamic Suggested Code: DMEPOS Fee Ceiling: L1951 $905
Spastic Drop Foot
: Initial Visit
Arizona Dorsiflex Assist Suggested Code: L1940, L2210, L2330, L2820 DMEPOS Fee Ceiling: $1174 Richie Dynamic Assist Suggested Code: L1970, L2210, L2820 DMEPOS Fee Ceiling: $976
Rigid Equinovarus • 736.71
• 754.51
• 728.85
Equinovarus, acquired Equinovarus, congenital Spasm of muscle
Rigid Equinovarus
: Initial Visit Arizona AFO, Tall, foot plate to sulcus Suggested Code: L1940, L2330, L2820 DMEPOS Fee Ceiling: $1099 Arizona AFO, Extended Suggested Code: L1960, L2330, L2820 DMEPOS Fee Ceiling: $1179
Achilles Tendonitis, Achilles Tendon Tear
845.09
726.71 Achilles tendon strain, tear Achilles tendonitis
Achilles Tendonitis, Achilles Tendon Tear : Initial Visit Ossur Equalizer Low Top Ossur Equalizer Premium Aircast SP Walker Pneumatic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Aircast FP Walker
Achilles Tendonitis, Achilles Tendon Tear
: Second visit Ossur Formfit Ossur Exoform Night Splint, posterior or dorsal Suggested Code: DMEPOS Fee Ceiling: L4396 $180 Ossur Airform
Achilles Tendonitis, Achilles Tendon Tear
: Follow up visit Bauerfeind Achilleotrain Suggested Code: DMEPOS Fee Ceiling: L1902 $90.11
Metatarsal Fracture
733.10
825.25 Stress fracture, unspecified Fracture of the metatarsal bone
Metatarsal Fracture : Initial visit Ossur Equalizer Low Top Walker Suggested Code: DMEPOS Fee Ceiling: L4386 $171 Darco Med-Surg Walker Suggested Code: DMEPOS Fee Ceiling: L2999 Patient pays
Metatarsal Fracture : Follow up visit PowerStep readymade orthotic Suggested Code: L2999 DMEPOS Fee Ceiling: Patient pays
Charcot, Active
713.5
Arthoropathy associated with neurological disorder 715.17 Osteoarthritis, localized foot and ankle
Charcot, Active, Goals of Treatment
Prevent further deformity Obtain a plantargrade foot Avoid excess pressure on skin
Charcot, Active: Initial Visit Total Contact Cast, non weight-bearing Bledsoe Charcot Conformer Aircast XP Diabetic Walker Suggested Code: DMEPOS Fee Ceiling: L4360 $312 Suggested Code: DMEPOS Fee Ceiling: L4360 $312
Charcot, Active, Follow-up Visit CROW if patient non-compliant and bearing weight Suggested Code: DMEPOS Fee Ceiling: L1960, L2340, L2820 $1228
Charcot, Static
715.17 Osteoarthritis, localized foot and ankle 735.9
Unspecified deformity of ankle and foot, acquired
Charcot, Static, Treatment
Custom mold shoes, offset heels and rocker bottoms
Suggested Code: DMEPOS Fee Ceiling: A5501, A5506, A5503 $519
AZ AFO with removable footbed and Custom mold shoes
Suggested Code: L1940, L2330, L2820, A5501, A5506, DMEPOS Fee Ceiling: A5503 $1618
Disclaimer:
Suggested codes are based on publically available information and are offered as a convenience to physicians. The authors make no claims, promises or guarantees as to the availability of reimbursement for any of the suggested products. It is within the sole discretion of the physicians to determine the appropriate billing code for a product as well as whether the use of a product complies with medical necessity and other documentation requirements of the payor. The authors and the American Academy of Podiatric Practice Management accept no responsibility whatsoever in this regard.