Ankle Foot Orthosis (AFO) & Knee Ankle Foot Orthosis (KAFO) Questions & Answers (Q&As)
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- If the treating practitioner orders a prefabricated orthosis, but the orthotist's functional evaluation determines the patient needs a custom fabricated brace, is a new Standard Written Order (SWO) needed?
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Yes. When providing these items, the supplier must provide the product that is specified by the treating practitioner. In addition, there must be documentation in the supplier's records to support the medical necessity of that type device rather than a prefabricated orthosis. This information must be available upon request.
Originally published: 05.05.20
Reviewed: 12.08.23
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- Are there any circumstances under which a beneficiary can receive a new ankle foot orthosis prior to the 5-year reasonable useful lifetime (RUL)?
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Orthotics may be replaced in cases of loss, irreparable damage, or change in the patient's physical condition. Irreparable damage may be due to a specific accident or to a natural disaster (such as a fire or flood). Contractors may request documentation confirming details of the incident (such as a police report or insurance claim report) or medical records documenting the change in condition.
Please refer to the "Replacement Orthosis During Reasonable Useful Lifetime" documentation checklist and the "Same or Similar Denials for Orthoses and the Appeals Process" article for additional information.
Originally published: 05.05.20
Reviewed: 12.08.23
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- If a patient receives a walking boot (L4360) after surgery and uses the device for 6-8 weeks while the foot heals, will Medicare cover a replacement device a year or two later if there is a new fracture?
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A new orthotic could be considered for payment if the documentation from the treating practitioner supports a change in patient condition, or it documents why the original device is no longer applicable. Suppliers should work with the beneficiary to determine if the original device is still in their possession and could be used.
Please refer to the Replacement Orthosis During Reasonable Useful Lifetime documentation checklist and/or the Same or Similar Denials for Orthoses and the Appeals Process article for additional information.
Originally published: 05.05.20
Reviewed: 12.08.23
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- In the following scenario, a patient receives a custom AFO that is ordered by the treating practitioner and is unable to tolerate it. If the treating practitioner orders a different custom AFO, will the second AFO deny as same or similar?
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Yes, the second device would be denied for same or similar. The orthotist (supplier) should work with the beneficiary and the treating practitioner to provide the custom brace that meets the beneficiary's needs and fits appropriately. Documentation demonstrating a change in condition would be needed to justify a second brace during the RUL.
Please refer to the "Replacement Orthosis During Reasonable Useful Lifetime" documentation checklist and/or the "Same or Similar Denials for Orthoses and the Appeals Process" article for additional information.
Originally published: 05.05.20
Reviewed: 12.08.23
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- How is it recommended that we bill for a replacement AFO that has fractured or broken and is not repairable before the 5-year RUL period?
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If the irreparable damage was due to a specific accident or natural disaster, the item may be replaced. Use the RA modifier on DMEPOS claims to denote instances where an item is furnished as a replacement for the same item which has been lost, stolen, or irreparably damaged. The supplier may be asked to provide documentation of the incident. Refer to Chapter 3 of the Supplier Manual for information on replacement.
Originally published: 05.05.20
Reviewed: 12.08.23
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- What is the allowed amount for L4210?
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HCPCS L4210 is used for repair or replacement of minor parts that do not have an assigned code, and the claim must include a narrative description of each item billed under this code. The allowed amount will be determined on a claim-by-claim basis. Refer to Chapter 10 of the Supplier Manual for information on pricing.
Originally published: 05.05.20
Reviewed: 12.08.23
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- Are medical records from the treating practitioner required for repairs of an orthosis?
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In the case of repairs to a beneficiary-owned DMEPOS item, if Medicare paid for the base equipment initially, medical necessity for the base equipment has been established.
With respect to Medicare reimbursement for the repair, there are two documentation requirements:
- The treating practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary.
- Any of the following may serve as documentation justifying continued medical need of the AFO:
- A recent order/prescription by the treating practitioner for refills of replacement components (such as soft interfaces). The order must be dated within the preceding 12 months.
- A medical record from the preceding 12 months showing usage of the item. And
- Any of the following may serve as documentation justifying continued medical need of the AFO:
- Either the treating practitioner or the supplier must document that the repair itself is reasonable and necessary.
Originally published: 05.05.20
Reviewed: 12.08.23 - The treating practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary.
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- Can an Advance Beneficiary Notice (ABN) be used when we are unsure if the beneficiary has obtained same or similar equipment within the RUL?
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There must be a specific, identifiable reason to believe that Medicare may not pay for certain DME items ("same or similar equipment"). This means that you must obtain all the possible information from beneficiary in order to determine whether "same or similar equipment" has previously been provided to that beneficiary. You should ask very specific questions when providing items to Medicare beneficiary.
When providing equipment to beneficiary, the following information should always be obtained:
- The beneficiary's correct Medicare ID
- If the beneficiary currently has or had an identical or similar item(s) in the past, you should obtain specific information about:
- When the beneficiary received the item(s), and if the item(s) was returned, when, and why
- Who supplied the item(s)
- Where the item will be used
- A signed and dated written order from the treating practitioner
- Clinical documentation that demonstrates any change in medical need
You may also access JB and/or JC information about previously submitted same or similar orthotics through the myCGS web portal or by submitting a written inquiry that includes a copy of the signed and dated order by the treating practitioner.
If there is no indication that same or similar equipment has been previously obtained, you would not have reason to provide an ABN. If the beneficiary or the beneficiary's authorized representative is unable to respond fully on the issue of "same or similar equipment," you may issue an ABN.
Refer to Chapter 3, Section 13 of the Supplier Manual for more information.
Originally published: 05.05.20
Reviewed: 12.08.23
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- Can a claim be submitted to the DME MAC for the following scenario: The orthotic will be used after ankle, foot, or knee surgery and is provided prior to inpatient hospital admission?
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No, a claim should not be submitted to the DME MAC in this situation. CMS developed the Medicare DMEPOS Improper Inpatient Payments Fact Sheet to help you bill correctly.
Originally published: 05.05.20
Reviewed: 12.08.23
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