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Ankle-Foot/Knee-Ankle-Foot Orthosis

CODING, COVERAGE AND REIMBURSEMENT

General

LCD: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33686&ContrID=140

Policy Article: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52457&ContrID=140

Walking boots

  • HCPCS:

  • Coverage requirements:

  • Frequency of replacement allowed by Medicare:
  •  
  • Non-covered conditions:
A foot pressure off-loading/supportive device (A9283) is denied as noncovered (no Medicare benefit), because it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body.


  • Billing reminders:


Static/dynamic Ankle-Foot Orthosis 

  • HCPCS:
    •  L4396 or L4397 is covered, a replacement interface (L4392)
  • Coverage requirements:

  • Frequency of replacement allowed by Medicare:
    •  If code L4396 or L4397 is covered, a replacement interface (L4392) is covered as long as the beneficiary continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one (1) per 6 months. Additional interfaces will be denied as not reasonable and necessary.
  • Non-covered conditions:
    • A static/dynamic Ankle-Foot Orthosis (AFO) (L4396, L4397) and replacement interface (L4392) are denied as noncovered (no Medicare benefit) when they are used solely for the prevention or treatment of a heel pressure ulcer because for these indications they are not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).
  • Billing reminders:


Foot drop splint/ recumbent positioning device 

  • Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394)




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