Neuro Exam 2
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The last few installments of this column have provided some insights into how the neurological component of your examination provides both clinical and coding justification for specific AFO. Today’s installment (with a very abbreviated medical history) centers on a patient who is a 56 year old 6”4 250 lb. hypertensive nonsmoking nondiabetic male who works on a loading dock. He notices that his left foot has been dragging the last few months. He complains of his left leg being tired and he just cannot take care of things around the house as he used to. He has recently seen a neurologist and has undergone both a spinal MRI and EMG/NCS of the lower extremities. These reveal mild spinal stenosis of L4-5 and some EMG/CNS abnormalities to the left lower extremity consistent with left side radiculopathy. The neurologist believes that with spinal injections he can reduce the inflammation but believes the patient can also benefit from an AFO to reduce the foot dragging and promote improved left lower extremity biomechanics.
The neuro exam reveals a left side foot drop with some (2/5) dorsiflexion power upon resistance and improved dorsiflexion without resistance (3/5). Sensations on the left foot to all dermatomes are reduced. Left Achilles reflex is 2/5 vs 4/5 on right. Patella reflexes are normal bilateral.
Gait has a decided foot drop with foot slap at contact and toe dragging in propulsion.
You agree that an AFO is required and the patient agrees. But now the inevitable question, which type?
Let’s start with OTC vs Custom?
How long do you expect the patient to require the AFO? There is no way to know and is more likely long term (>6 months) rather than short. Hence a custom device is needed.
Next question: Is it custom fabricated or custom fitted? The patient is going to need a dorsiflex assistive and plantarflex resistive hinged device and one will need to adjust the amount of dorsiflexion assistance and plantarflexion resistance based on the patient’s needs. Hence a custom fabricated device is required.
Height: Does the patient qualify for a low profile or standard height AFO.
Given his height, weight and occupation, a standard height AFO is most likely going to be needed.
Does the patient require a soft tissue interface? There is nothing in the abbreviated note to justify a below knee soft tissue interface other than the neuropathy. One could justify its need by elaborating on the neuropathy and its protective elements in the clinical treatment plan.
The clinical treatment plan should then read something like this:
The lower extremity examination and his neurologist confirm that this patient requires an AFO and he will require it for more than 6 months and perhaps for his lifetime. This defends the need for a custom AFO.
Due to the patient’s height, weight and occupation, a custom fabricated standard height hinged AFO (L1970) with graphite lamination (L2755) is required.
Due to his neuropathy the skin needs to be protected, and a below soft tissue interface (L2820) is needed.
Due to his foot drop related to weak dorsiflexion and resultant plantarflexion slap, he requires an additional hinge modification of dorsiflexion assist/plantarflexion resist (L2210).
For Medicare and most third-party claims, each claim line should contain one HCPCS code and both the KX and LT modifier. The diagnosis of left foot drop foot M21.371 can be used as the primary diagnosis along with M48.06 (spinal stenosis) as a secondary diagnosis.
From this real-life example, one can see that concise clinical documentation is crucial in justifying the clinical treatment plan.
More examples will follow over the next several months, albeit not sequentially.
