06/12/2018

Correct Billing for Patient with Severe Plantar Fasciitis-Medicare

I have a patient with severe plantar fasciitis who has Medicare. Is it appropriate to bill L4397 (Night Splint) and L1902 (AirHeel) during the same visit?

If both the night splint and the air heel are being billed to the patient to address issues with plantar fasciitis on the same foot, only HCPCS code L4397 should be billed to Medicare since L1902 would be denied as inclusive to the more expensive DME item, even though they are separate items.

If each item will be used on a different foot to address plantar fasciitis, separate payment will be allowed by Medicare for the AFOs.

L4397

Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

Lay Description (Code):

A static ankle foot orthosis (AFO) is a prefabricated AFO that may be adjustable for fit and positioning and is designed to accommodate an ankle with a plantar flexion contracture up to 45 degrees. It applies a dorsiflexion force to the ankle, allows pressure reduction, is used by a patient who is minimally ambulatory or nonambulatory, and has a soft interface. AFOs extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. A dynamic AFO allows a more gradual stretch, and allows the patient to progress as tolerance is increased. The low-load stretching also allows the patient to maintain gains in range of motion. The dynamic AFO has an adjustable cord and articulating dorsal shell that assists in controlling the degree of stretch, while at the same time allowing for an adjustment of the cord's tension. This code includes the fitting, adjustment, and supply of a static or dynamic ankle foot orthosis.

L1902

Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

Lay Description (Code):

Ankle orthotics, gauntlets, and supports are generalized under the heading ankle-foot orthosis (AFO). (An exception within this range is the simple, prefabricated neoprene sock-type device.) AFOs within this range are prescribed for a variety of conditions for ambulatory patients, including congenital anomalies, pronation of the ankle, tendon problems, arthritis, and amputation. These devices generally extend well above the ankle, often to the upper calf, and may accommodate multiple planes of ankle movement. Some devices also limit ankle movement. The units may be built from standardized molds or custom fabricated from a plaster impression taken of the patient's foot and ankle. The units themselves may be made of metal, plastic polymers, or leather, sometimes in combination, and usually with various fabrics, cushions, and closure systems. A custom-fabricated orthosis involves substantial work, such as cutting, bending, molding, or sewing. It may involve the incorporation of some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item. Polypropylene models are close fitting and are often worn inside the shoe. Gauntlets usually feature lateral and medial stabilizers to address eversion and inversion, arch support, heel lock, padded tongue to facilitate application, and side panels for additional reinforcement. Fitting and adjustment is included in the supply of the product. Some gauntlets use natural heat therapy to gently warm troubled areas on the ankle and foot. They consist of stabilizers (usually plastic) on either side to help resist inversion and eversion. Other features usually offered are arch support and complete heel lock, elastic back section to eliminate blistering, padded tongue to facilitate application, and side panels for more reinforcement. A molded-to-patient-model orthosis is a particular type of custom fabricated orthosis in which an impression of the foot is taken, by means of a plaster cast, CAD-CAM technology, etc. This impression is then used to make a positive model (of plaster or other material) of the body part to be braced. The orthosis is then molded on this positive model to be fit exactly to the patient's foot. It may require several castings and fittings by an orthotist/MD.