01/14/2013 Paul Kesselman, DPM
Confusion Over New AFO Height Requirements (Josh White, DPM, CPed)
I respectfully disagree with the recent letter
by Josh White (owner of SafeStep). He and other
advertisers are advising that everything is okay
with the AFOs their companies provide to the
podiatry community. Whether that is true or
false is subject to the answers to the questions
I am outlining below.
Q: Is it mandatory that the PDAC verify custom
(and pre-fabricated AFOs)?
A: In a previous letter, I advised that the
answer to #1 is NO with the exception of devices
which meet the criteria for L1906 a pre-
fabricated multi ligamentous ankle support. Only
those devices must receive PDAC verification.
Q: If the PDAC does review and issue
verification for a specific product does that
automatically qualify the device for payment?
A: My previous LTE advised the readers that
based on communication with the PDAC medical
director himself, that PDAC does not issue
payment, coverage or reimbursement directives.
The PDAC may advise the DME MAC’s on payment
issues, but the final regulations concerning
payment, coverage and reimbursement is up to the
DME MAC.
In this case, the LCD covering AFOs is owned by
DME MAC C. As a means to refresh all of our
memories, the PDAC’s main purpose is to identify
whether or not a specific product matches the
HCPCS coding definition, which are stipulated by
the HCPCS Common Work Group. That is a far cry
from ever verifying coverage, reimbursement or
payment for any device.
Since Dr. White and many others are confused,
I’d like to use some parallel scenarios in both
the DME and Part B Medical/Surgical world to
better illustrate the issues here.
In the DME world, most podiatrists provide their
diabetic patients with therapeutic shoes and
inserts. The inserts must be verified. So
assuming you provide a patient with 4 pairs of
inserts, one may say that all four should be
covered. The answer is obviously up to 3 are
covered and one pair is not. Here the PDAC has
issued the HCPCS verification, yet the DME MAC
is stipulating we won’t cover that fourth pair.
A second analogy, would be the diabetic patient
who wants a therapeutic shoe which may have been
PDAC approved (just as an AFO), yet the patient
does not have one of the six qualifying
diagnosis listed in the T. Shoe LCD.
In the Part B world, a patient presents for at
risk (routine) foot care with no at risk class
findings or LOS. You trim the toenails (11719)
and trim the hyperkeratosis (11055). Is this
covered? The procedures certainly match the CPT
definitions, yet the LCD says this is not
covered.
Q: Does the PDAC verification letters provide
proof that these devices meet the LCD height
requirements of the LCD?
A: Most of the PDAC verification letters were
issued prior to the implementation of the
draconian height requirements, stipulated by the
LCD. I have yet to see Dr. White or any of the
advertisers who claim their PDAC verification
automatically qualifies their device for payment
provide any proof that these devices were in
fact verified with the new height requirements.
Q: Does PDAC provide any written guidance on
this controversy?
A: The PDAC has a payment guide which does in
fact provide written proof of the explanations I
have provided. Below you will find some verbiage
which should bring this controversy to a
grinding halt: “The PDAC does not provide
billing advice. They only provide coding advice.
The PDAC receives frequent inquiries regarding a
billable HCPCS code and a payable HCPCS code. One
may think the two are the same; however, this is
not the case. If the HCPCS code is billable to
the DME MAC it does not necessarily mean it is
payable. A billable HCPCS code is one that can
be submitted on a claim to the DME MAC. A
payable HCPCS code is one that will be
considered for payment by the DME MACs only if
the item meets:
1. The definition of Durable Medical Equipment
(DME);
2. Falls under a benefit category, which CMS
defines as the category of the Medicare
program to which an item or service applies.
Examples of benefit categories include
durable medical equipment, physician services,
inpatient hospital services, and diagnostic
tests, and;
3. Is covered under other general DME guidelines.
Specific details can be found on the applicable
DME MAC web site for which you are billing.”
The source document for this is located on the
PDAC website and may be found at:
https://www.dmepdac.com/docs/search/dmecs_guide.p
df 07/18/12”
The obvious conclusion here is that if the DME
MAC LCD precludes coverage for one reason or
another then payment should not be made.
In the simplest of terms, the PDAC medical
director and the PDAC website are the go to
authority. Dr. White and the other advertisers
who claim that PDAC verification automatically
qualifies their devices for payment are clearly
not providing accurate information to the
readers or their clients. I see no grey here
whatsoever.
Q: So where do I as a practitioner go from here?
A: Since the device you are making is custom, be
sure and incorporate the fibular neck into the
cast and mark it on your cast. Be sure and
incorporate this on your order form so the lab
understands you wish to have the uprights
fabricated to the height stipulated by the LCC
(2-4 cms from the fibular head). Be sure and
denote this in your progress notes.
If the device is PDAC approved, not custom
fabricated and falls short of the heights
mandated, then despite PDAC’s approval, the
device would not qualify for reimbursement
I can’t stress this enough, to the advertisers
and readers that PDAC approval by and of itself
does not automatically qualify your AFO billing
for reimbursement.
To summarize for all:
PDAC has made it clear and IN WRITING that it is
NOT THEM who makes reimbursement policy but the
DME MAC!
For advertisers to suggest that PDAC approval is
tantamount to coverage only revs up the
confusion factor.
I hope these explanations will help to motivate
all to work together in a spirit of cooperation
rather than in the current climate of distrust
and competition. Our goal should be to better
educate our colleagues and work together to get
this unscientific LCD overturned.
Paul Kesselman, DPM, Woodside, NY,
drkesselmandpm1@hotmail.com
01/12/2013 Jason Kraus, Don Pierson
RE: Confusion Over New AFO Height Requirements (Paul Kesselman, DPM)
I read with interest Dr. Kesselman's post
regarding the new height requirements for AFO's.
We are in complete agreement with Dr.
Kesselman's statement regarding the ultimate
responsibility belonging to the party who bills
Medicare. We also believe that the new policy
article makes little clinical sense and should
be reconsidered in light of a voluminous amount
of scientific literature supporting the efficacy
of the braces commonly used in podiatry and
orthotics and prosthetics today. We are being
asked to operate in a bizarre environment where
two different Medicare contractors are stating
completely opposite positions about how to apply
the new policies. If that weren’t confusing
enough there are two different policy articles
which are currently valid which contain
contradictory information.
Dr. Kesselman’s post might have given PM News
readers the sense that companies who have been
advertising/communicating information regarding
the current AFO conundrum are somehow misleading
readers. We are not certain which advertisers he
was referring to, but as it relates to Langer
and Arizona AFO, nothing could be further from
the truth. Langer and Arizona AFO have had
considerable contact with the Medicare officials
which Dr. Kesselman references in his post. The
responses both from the Senior Medical Director
and the PDAC officials who crafted the new
definitions were presented in the information
that was contained in our advertisement. While
Dr. Kesselman states, in his opinion he does not
agree with the information, I think it is unfair
to suggest that we are not presenting the facts
as we know them to be. We have had many
customers who also called Medicare directly and
were directed to bill as we identified in our
ads. It should be noted that the American
Orthotic and Prosthetic Association (AOPA) is in
agreement with our interpretation of the policy
articles.
Most importantly, it should be noted that we
have offered all podiatrists the option of
making any custom AFO to whatever height
requirement they prescribe. Because each of our
AFO's are 100% custom made it is easy to extend
the height as long as practitioners send in a
cast that is at least as high as their
requirements. Both Langer and Arizona AFO have
always offered higher AFO’s as part of their
product lines. Making braces at these new
heights is something that we have been doing for
decades based upon the prescriptions from our
clients. Since the new policy article has come
out, we have also offered to make our commonly
used shorter AFO’s available in the new higher
versions. It is important that practitioners
avoid any “gimmicks” to get around Medicare
policy. AFO’s need to be fabricated in
accordance with good manufacturing practices and
technical standards in order to comply with the
new policy. Medical necessity requirements are
unchanged and positive patient outcomes should
be the guiding principles for your AFO
prescriptions
It is our belief, based both on the content of
current PDAC and DME MAC policy articles and on
conversations with Dr. Hoover, the DME MAC
Senior Medical Director and others at Medicare,
that Arizona style gauntlets, including our
SAFO's SMO;s PLS's, HAFOs as well as Langer
Gauntlets, should be coded as always. Should
Dr. Kesselman receive confirmatory information
that contradicts this, we will convey this new
information to our customers. It is my hope that
for the benefit of practitioners, patients and
AFO manufacturers that Medicare lowers the AFO
height requirement and maintains the Arizona AFO
type Advisory currently in effect.
Dr. Kesselman and other members of the APMA DME
subcommittee should be commended for their
efforts to fight these new rules and to obtain
clarity in this vitally important area of
podiatric practice.
Jason Kraus – Executive Vice President, Langer
Biomechanics
Don Pierson – Vice President, Arizona AFO
01/11/2013 Josh White, DPM, CPed
Confusion Over New AFO Height Requirements
The recent “Article for Ankle-Foot/Knee-Ankle
Foot Orthoses – Policy Article – Effective
January 2013” has created much confusion
regarding how high AFOs need to extend to
qualify for Medicare coverage. The article
poorly describes two different “usually”
required heights, one, “between the proximal
border of the gastrocnemius and the apex of the
head of the fibula (a region that is generally 2-
4 cm distal to the apex of the head of the
fibula)” and the other “within 1.5 inches distal
to the apex of the head of the fibula”.
The full text of the section describing the
required height reads as follows:
Ankle-foot orthoses described by codes L1900,
L1910–L1990 extend well above the ankle (usually
to near the top of the calf) and are fastened
around the lower leg above the ankle. The
terminal height of an AFO shall be located
between the proximal border of the gastrocnemius
and the apex of the head of the fibula (a region
that is generally 2-4 cm distal to the apex of
the head of the fibula). These features
distinguish them from foot orthotics which are
shoe inserts that do not extend above the ankle
and ankle gauntlets described by codes L1902–
L1907.
Ankle-foot orthoses extend well above the ankle
(usually to near the top of the calf) and are
fastened around the lower leg above the ankle.
Specifically, the proximal border of an AFO
shall terminate within 1.5 inches distal to the
apex of the head of the fibula. These features
distinguish them from foot orthotics which are
shoe inserts that do not extend above the ankle.
http://www.ngsmedicare.com/wps/portal/ngsmedicare
/!
ut/p/c5/pY5NC4JAEIb_kTPrOrt1lPI7FTRK9xIWEkKrHcLAX
59YV_XQzPF93g9QMH5b9c29ejVdWz2gACUumPC97ZKFmBNh4G
Am41yaaDE4Q-mPUDlCYb77QvEWMbBF7noe8vREKxGL7kT-
5TZX56uJWPBP-szZ-
NNnGlJa1jd8uf9EK_sklKDkbH5kwhHKAEJQzVUb75s20BCMiJ
FgyCRnJC0oQkj8Ttfw1H0UHUTmZP5QDLX9Aavv4Ds!/dl3/d3
/L2dBISEvZ0FBIS9nQSEh/
Fortunately, the bottom of the Article states
that to get coding advice,
“Suppliers should contact the Pricing, Data
Analysis, and Coding (PDAC) contractor for
guidance on the correct coding of these items.”
AZ AFO Advisory Article
Advisory Articles are written jointly by PDAC
and the DME MAC Medical Directors. Advisory
Articles to provide additional, clarifying
information related to coding of DMEPOS. It is
advised to review any LCDs and Policy Articles
that may be related to the Advisory Article
topic as well.
https://www.dmepdac.com/resources/index.html
To clarify the codes to be used for Arizona type
AFOs, PDAC issued an Advisory Letter that
remains active on it’s website:
https://www.dmepdac.com/resources/articles/2011/1
1_15_11.html
This advisory states:
For the Arizona Short and Arizona Tall, or
similar custom fabricated braces, only the
following codes should be used:
L1940 Ankle foot orthosis, plastic or other
material, custom fabricated
L2330 Addition to lower extremity, lacer
molded to patient model, for custom fabricated
orthosis only
L2820 Addition to lower extremity orthosis,
soft interface for molded plastic below knee
section
L2330 is used whether the closure is a lacer
closure or a Velcro closure. L2820 is used only
if a soft interface, either leather or other
material, is provided.
This Advisory reminds suppliers to “check the
product listing on Product Classification List
located on Durable Medical Equipment Coding
System (DMECS), if there are any changes”. As
of January 9, 2013 the assigned coding for these
devices are indicated as appropriate.
This Advisory offers suppliers with questions
about correct coding to “contact the PDAC
Contact Center at (877) 735-1326 during the
hours of 8:30 a.m. to 4:00 p.m. CT, Monday
through Friday, or e-mail the PDAC by completing
the DME PDAC Contact Form located on the PDAC
website: https://www.dmepdac.com/.”
PDAC Verification
PDAC (Pricing, Data Analysis and Coding) is the
Medicare contractor that:
• “establishes, maintains and updates all coding
verification decisions on the Product
Classification List that is available on DMECS”
• “Provides coding guidance for manufacturers
and suppliers on the proper use of the
Healthcare Common Procedure Coding System
(HCPCS)”
https://www.dmepdac.com/
PDAC maintains a listing of products evaluated
and assigns coding verification. It displays
the effective begin date and when appropriate,
effective end date.
Josh White, DPM, CPed, President, Safestep,
joshwhite@safestep.net
01/09/2013 Paul Kesselman, DPM
Confusion Over New AFO Height Requirements
Lately ,there has been considerable confusion
concerning the new AFO LCD. APMA and leaders of
other professions have been working diligently
to overturn the height requirements which have
no scientific basis. Review of the source
documents used by Medicare officials, reveals
they were published years ago and the height
requirements, as stipulated by Medicare were
taken out of context. Despite strong objections
by APMA and other stakeholder associations, the
current height regulations as stipulated in the
AFO LCD are required.
Questions abound concerning whether one style of
AFO vs. another need to meet these absurd height
requirements. Advertisers may have seized on
this apprehension to assure their clients
that their products have conformed with the new
policy.
Most recently, there have been several companies
advertising their products as PDAC-approved
AFO's. These advertisements either imply or
emphatically state that the use of their
products should remove all doubt in the readers
mind over compliance with the new AFO LCD.
It is my opinion that devices which may have
been PDAC approved prior to the
institution of the current AFO LCD (January 1
2012) and which do not meet the height
requirements stipulated in the policy are
nonetheless, not reimbursable.
That is my opinion. I am awaiting confirmation
from CMS officials on this point as well
as still hoping that the DME MAC Medical
Directors will reopen the discussion over height
requirements for AFOs.
At present, the only fact we have concerning
PDAC and the LCD is that no AFO, other than pre-
fabricated ankle braces, typically used for
ankle sprains (L1906) is required to have a PDAC
verification.
I certainly applaud the attempts to properly
educate our members irrespective of the source.
However, one should not be lulled into a false
sense of security based on commercial
advertisements alone.
It's worthwhile to reiterate that the party who
bills Medicare will ultimately be held
accountable.
On Tuesday evening, APMA will be sponsoring a
free webinar for its members on DME issues. The
two topics open for discussion are Therapeutic
Shoes and AFOs. I will be accompanied on this
webinar by Harry Goldsmith. I urge the readers
to contact APMA's Health Policy Department or
their local state component society for sign up
information.
Paul Kesselman, DPM, Woodside, NY,
drkesselmandpm1@hotmail.com
