Hello Listserv!
I wanted to thank everyone who took time to respond to my question. It
seems that most people were in favor of using the L5020 rather than mixing
prosthetic and orthotic codes. Several of you requested that I post the
responses so I’ve included those below.
*Original post:*
*Hello Listserv Community,I have a question that seems like it should have
been concretely answeredyears ago and yet I cannot find clear guidance
anywhere (With the exceptionof a discussion from 2013 in the O and P
Edge).I have a Medicare patient that has recently undergone a TMA. I would
liketo pair a toe filler with a OTS carbon fiber anterior panel AFO
(L1932).Research that was published in 2007 during our
state-of-the-scienceconference shows the clear functional benefits of using
a tibial tubercleheight partial foot prosthesis (not to mention wound
prevention). Thisshould be our standard of care at this point as I see
it.My question is this, How do you code and bill this through Medicare
sinceL5000 and L1932 are from separate LCDs? The patient has ankle
equinus,like most TMAs, so I have justification to bill an AFO. Would you
(*A*)bill them all on one delivery ticket using TMA as the primary
diagnosis andankle equinus as the secondary diagnosis? Or (*B*) separate
the claimsonto separate delivery tickets using TMA for the toe filler and
ankleequinus for the AFO? Or (*C*) do something else that I haven’t
thought of.I really appreciate any links you have to Medicare guidelines on
this ifyou have found any. *
*Responses:*
No. You keep it simple.
You bill separate. One for afo and one for PFI. Nothing wrong there.
Bill it as a prosthesis, not as an orthotic. I believe the code is L5020
but double check me. Bill for carbon acrylic and for custom distal
padding.
The code for a tibial tubercle height partial foot is L5020. I would use
that if that is what they are needing. Just make sure your documentation
explains how it all works together.
You want to bill the L5020 partial foot tibial tubercle height with toe
filler.
Hi Ashley,
I have attached the recommended coding for using an AFO as part of a
partial foot prosthesis. You do not bill the L1932 AFO code since you are
converting it into a partial foot socket that goes above the ankle you only
use the prosthetic socket codes. I hope this helps, please do not hesitate
to reach out if you have any additional questions. The fees are from 2019
so they are outdated, sorry about that but the coding is what we still use.
Kind Regards,
Justi Appel, CO, BOCP, PhD, FAAOP
Director of Education and Clinical Support
Allard USA, Inc.
Preview attachment Allard Partial Foot Coding Supplement.pdf
Allard Partial Foot Coding Supplement.pdf
494 KB
I would go after the AFO and just add a simple toe filler to it. That would
be better than billing for a toe filler and getting the AFO denied.
Funny bc I literally ran in to this yesterday. I would bill Both codes on
one ticket. And put both diagnoses on the claim. Reference ankle equines
afo and reference amputation for toe filler. It should
Not matter which is listed as primary or secondary. What matters is which
diagnosis is paired with which code. Let me know if you have questions.
Just Bill L5020, which is a above ankle partial foot prosthesis. It is the
most accurate coding.
You bring up a good question. I don’t really have an answer for you aside
from option C. For all of my TMAs I do custom partial feet prosthesis, in
other words, a custom prepreg orthosis built around a partial foot toe
filler. It keeps all your codes in the prosthetic family, will last much
long than the OTS carbon brace which are prone to breaking, will
accommodate varus/valgus /equinus much better, and you can still bill the
L5000 down the line when the toe filler wears out.
The codes would be L5020, L5976, L5661, L5637, L5940
*Add L8420 x(6) for multi-ply prosthetic socks
Bill with L5020 as the listserv indicated. You will need to fab it as one
unit not an insert and an AFO.
I like the thought and am very familiar with the approach. I would just
remind you that to have the AFOs approved, don’t forget the weakness or
deformity of the ankle in the physician chart notes to have the AFO
approved. Medicare does not consider the amputation as an adequate reason
for the AFO.
Reach out to Allard as they have addressed this. Making a ‘socket’ like a
UCB or SMO with correct calcaneal angle and fixing it to a Toe Off is
billed as a tibial tubercle height partial foot prosthesis (L5020?). I
have used several successfully as well as having carbon anterior panel AFOs
custom made by other central fabs. It is about restoring length of foot
and correcting a-propulsive gait as well as protecting distal end from
shear.
Thank you all again!
Ashley Seefeld, CPO
Berke Prosthetics and Orthotics
2001 Winward Way, Suite 100
San Mateo, CA 94404
P: (650)-570-5861
F: (650)-365-5896
