The Centers for Medicare & Medicaid Services (CMS) has posted several dozen revisions to the coding of orthoses in Jurisdiction A, which includes Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.
The Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction A posted the revisions to the Local Coverage Determinations (LCDs) and Policy Articles (PAs) on March 9, 2009. A summary of the revisions is listed below. To view the complete LCDs and PAs, visit www.medicarenhic.com/dme/medical_review/mr_lcd_current.shtml
Ankle-Foot/Knee-Ankle-Foot Orthosis
LCD
Revision Effective Date: April 1, 2009
Indications and limitations of coverage:
- Deleted: L-1901 from code range of AFO-KAFO used with ambulation.
HCPCS codes and modifiers:
- Revised: Code L-4360 descriptor.
- Deleted: Code L-2860.
Policy Article
Revision Effective Date: April 1, 2009
Non-medical necessity coverage and payment rules:
- Added: Noncoverage language for elastic support garments.
Coding guidelines:
- Deleted: Code L-1901 from the prefabricated orthoses list and from the from ankle-foot orthosis worn by ambulatory patients.
- Added: Code L-2770 is invalid.
- Revised: Removed Column I/Column II table in lieu of statement about billing replacement codes at time of initial issue.
- Revised: SADMERC to PDAC.
Knee Orthoses
LCD
Revision Effective Date: April 1, 2009
Indications and limitations of coverage:
- Added: ICD-9 diagnosis codes 844.0-844.2 and 996.40-996.49 to range of codes for L-1830, L-1832, L-1834, L-1843, L-1844, L-1845 and L-1846 in response to request for reconsideration.
- Deleted: Codes L-1800, L-1815, L-1825 from prefabricated knee orthoses.
- Deleted: Codes L-1800, L-1815, L-1825 from Base code & Addition Codes-Eligible for Separate Payment.
- Deleted: Codes L-1800, L-1815, L-1825 from Base code & Addition Codes-Not Medically Necessary.
HCPCS codes and modifiers:
- Revised: KX modifier.
ICD-9 Codes that support medical necessity:
- Added: ICD-9 diagnosis codes 844.0-844.2 and 996.40-996.49 to range of codes for L-1830, L-1832, L-1834, L-1843, L-1844, L-1845 and L-1846.
Documentation:
- Added: Clarified that use of KX modifier is applicable to both the base and addition codes.
- Revised: Changed DMERC to DME MAC.
Policy Article
Revision Effective Date: April 1, 2009
Non-medical necessity coverage and payment rules:
- Deleted: Codes L-1800, L-1815, L-1825 from the reasonable useful lifetime chart.
- Added: Noncoverage language for elastic support garments.
Coding guidelines:
- Deleted: Codes L-1800, L-1815, L-1825 from Base code & Addition Codes-Not Separately Payable.
- Deleted: Code L-2860.
- Revised: SADMERC to PDAC.
Spinal Orthoses: TLSO and LSO
LCD
Revision Effective Date: April 1, 2009
HCPCS codes and modifiers:
- Added: CG, GY
Documentation requirements:
- Added: Use of CG and GY modifiers with elastic spinal orthoses.
Policy Article
Revision Effective Date: April 1, 2009
Non-medical necessity coverage and payment rules:
- Added: Statement concerning noncoverage of elastic spinal orthoses.
Coding guidelines:
- Changed: SADMERC to PDAC.
