ORIGINAL POST
I am under the assumption that a soft interface (plastizote) and a metatarsal pad added to the inside the foot section of a custom plastic AFO should NOT be billed as L2830 (soft interface for molded plastic) because foot related supports are not covered by Medicare. Am I correct?
Randy McFarland, CPO Fullerton, CA
RESPONSES
I believe that L-2820 is for a totally lined AFO, plastizote or equal.
Be careful that you have medical justification for using it. Comfort I believe is not considered justification. Brittle or at risk skin would be a good example.
I am certainly not the authority on coding, but my understanding is that in order to use the L2820 in an AFO, 75% of the orthosis needs to be lined with the soft interface material. Although I do not personally bill for the addition of a metatarsal arch support, I would probably lean toward the L3080. I know that this requires being attached inside of a shoe, I could justify attaching it to an orthosis.
I think you should be able to get paid for any type of padding in an AFO. It does not specify that it is full length or that it is just the foot section that is covered in padding. You just need to be able to justify why it needs to be padded.
Foot related supports can be billed to Medicare if they are an “intricate” part used in conjunction with another orthosis. You have to have medical necessity for them and make sure that the KX modifier is used.
In order to use the L2830 code one needs to line at least 80% of the AFO.
This is what I was told at a 2003 coding seminar; and yes it would also be inappropriate even if the percentage were less as Medicare does not cover “foot related supports”.
I think L2820 has to cover 70 percent of the orthosis.
Randy, just do it. I think it could be justified. It’s like taxes. If you think it should be ok, do it and bill it. I would.
Why do you make that assumption? Is it because somebody told you not to code it this way, or you went to a seminar and the “the coding experts ”
advised against it? I would look at the reasons that this client is requiring this addition and examine the medical necessity and justify it based on that and either use the soft interface code which , I think, was created for additions like this and describes the addition or go through the steps describing the addition using the L2999.
If you add plastizote or a met pad to an AFO then they are “additions to the AFO”, not supports (such as arch supports). If the patient has a need for the addition it becomes a justifiable addition to the brace.(Brace side only).
They only (brace addition)item I am aware of Medicare denying regardless of need with a brace is the fracture sock code (as fracture socks are apparently not a covered benefit). Go figure –
I think this is a gray area.
Is the plastazote vacuumed in? Was it added later as an adjustment to an existing AFO? I believe you could argue it both ways. If it was part of the original AFO design, I do not see the problem with using L2820.
If it is an add-on later, it may be a bit unrealistic to code it that way.
Just some thoughts on the subject.
A soft interface needs to cover over 50% of the entire orthosis to be billable by the code L2830.
It would be L2820 as it is Bk not AK and I would consider this as a billable code for this service if medically necessary and delineated on the Rx.
