Recently, a new coding forum entitled codinghelpline.com was launched enabling colleagues to send in coding questions. Not surprisingly, as happens at many conferences, one subscriber asked the following probing question: Can you provide the appropriate diagnosis and documentation required to ensure my charting is appropriate specifically for a drop foot brace coded L1970 with soft tissue interface?
Well, the appropriate documentation would depend on many factors, now, wouldn’t it?
Two huge questions need to be answered:
Primarily what is causing the drop foot?
Secondarily but as important, is the diagnosis substantiated in your chart?
These types of questions, always take my back to High School when my algebra and geometry teachers, always lamented, “The answer to the question we pose is not all we want to see. We want to see your work. How did you get there? As in HS or College math, the answer (in this case a diagnosis) without showing proof (in this case a proper work up) will result in your failure of either a pre or post payment audit. Hence the answer to this question becomes quite complicated. However, not impossible. It just requires you to think and act like a physician and properly assess the patient. That is to show your work!
Here’s some additional food for thought:
From the AFO LCD perspective, with a few exceptions, there is not a list of required ICD10 listings for the majority of AFO.
Back to the question raised, why would a free range of motion AFO (L1970) be appropriate for a patient with a drop foot? Wouldn’t they also require some assistive and resistive technologies or instead be placed into a solid AFO (e.g. L1960)?
Is there only one etiology to a drop foot or are there literally hundreds?
These few questions, beings to scratch the surface of what workflow should be documented.
It really is not that difficult to document the medical necessity for this, or any type of AFO. It simply starts with performing a comprehensive history, physical examination and thorough gait analysis. At times, a consultation with another physician specialty may be in order. Once that is completed, one must be able to defend your management of the diagnosis (AFO choice) and how this will impact the patient’s functional improvement. This last step is what most physicians and even orthotists frequently fail to adequately document.
The next few installments will provide some easy to implement documentation tips using this one clinical example (drop foot brace). Hopefully this can serve as an example of just how easy it is to properly document the medical necessity for an AFO.
