11/10/2016

L4360 vs L4361

HCPCS Code: L4360 Long Description: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Question: If a podiatrist "with expertise" trims, bends, molds, or otherwise customizes a pre-fabricated pneumatic walking boot, can that podiatrist bill code L4360? If so, how does a podiatrist demonstrate to an insurer that the correct code is L4360, and not L4361? (since the manufacturer labelled the boot L4361 prior to office customization) Thank you for your expertise.

A walking boot labeled L4361 by the manufacturer, cannot be changed to a different code and submitted to insurance for payment. L4361 classifies the need for “minimal self-adjustment”; thereby countering the need for a podiatrist “with expertise” to trim, bend, mold, or other customize a pre-fabricated walking boot.

FROM LCD (Ankle-Foot/Knee-Ankle-Foot Orthosis)

For prefabricated orthoses (L1902, L1906, L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4350, L4360, L4361, L4370, L4386, L4387 and L4396-L4398), there is no physical difference between orthoses coded as custom fitted versus those coded as off-the-shelf. The differentiating factor for proper coding (see definitions in the related Policy Article Coding Guidelines) is the need for “minimal self-adjustment” at the time of fitting by the beneficiary, caretaker for the beneficiary, or supplier. This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training. Items requiring minimal self-adjustment are coded as off-the-shelf orthoses. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category.