Billing for Crow Boots and AFO Replacement Interface Material, Custom Knee Orthoses Codes

Denials are difficult to identify and time-consuming to appeal. If you have a billing question or a question about a denial, “Got FAQs?” can help you sift through the confusion and get you the answers you need. This month’s column addresses your questions about billing for CROW boots, redetermination forms, billing for replacement interface material on an AFO, and addition codes for a custom-fabricated knee orthosis.

Q: Is the new code L-4631, which became effective in 2011, replacing all of the individual codes for the CROW boot? I am located in Region A.

A: The Local Coverage Determination (LCD) for ankle foot/knee-ankle-foot orthosis code L-4631 (ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated), includes all additions including straps and closures. No additional codes may be billed. For more information regarding the proper coding for L-4631, visit www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11527_2011-02-04_PA_2011-01.pdf

Q: I recently submitted a redetermination request to Medicare Region C. My request was returned stating I did not use the most current request form. I have searched for the updated form and cannot find it. Where can I find this form so I can resubmit my claim to Medicare? There is a 120-day time limit on my denial, and it is getting close to the deadline.

A: Medicare released new reopening and redetermination request forms along with a checklist of documentation required. The reopening request form can be found at www.medicarenhic.com/dme/forms/DME_Reopening_Request_Form.pdf

The redetermination request form can be found at www.medicarenhic.com/dme/forms/DME_Redetermination_Request_Form.pdf. The redetermination request form checklist can be found at www.medicarenhic.com/dme/forms/Redeter_Req_Checklist.pdf

Q: We provided a patient with an L-4396 (static AFO, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment) and L-4392 (replacement, soft interface material, static AFO) in 2010. The patient has come in for a follow-up visit, and we replaced the soft interface material. Can we bill for the interface material replacement? If so, how often can we replace this for the patient?

A: If code L-4396 is covered, a replacement interface (L-4392) is covered as long as the patient continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one per six months. Additional interfaces will be denied as not reasonable and necessary. For more information, visit www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11527_2011-02-04_PA_2011-01.pdf

Q: I am a new billing manager for a Region A provider. I am billing for a custom-fabricated knee orthosis. The practitioner informed me that the code I should bill for is L-1840 along with the addition codes for this brace. What other codes should I be billing with the L-1840? Where can I find information on knee braces?

A: When billing for an L-1840 (KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated) as your base code, the addition codes that can be billed are as follows: L-2385, L-2390, L-2395, L-2397, L-2405, L-2415, L-2425, L-2430, L-2492, L-2785, and L-2795. For complete information on coverage and medical policies for knee orthoses, review the following document: www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L27263_2011-02-04_PA_2011-02.pdf

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