Recently a colleague asked whether he could be reimbursed for a soft tissue interface for an Ankle Foot Orthotics (AFO). Most readers here would automatically respond yes as there is a litany of add-on-codes in the AFO LCD.
However as is usually the case, the devil is in the details, and the correct answer is not so straightforward, nor should it be answered with an automatic yes or no. That old adage, “Just because a code exists does not automatically qualify one for payment” applies here.
Let’s work our way through the AFO policy so that one can understand the correct answer. As was noted in the past column, most if not all Local Carrier Determinations (LCD) have an attached Policy Article (PA). Most often coding clarifications are listed in the Policy Article attached to the LCD. Such is the case here.
The PA for AFO (A52457) states that add-on-codes, such as L2820, are only covered for custom fabricated AFOs. Since the AFO my colleague was billing was not custom fabricated, but was prefabricated and includes fitting and adjustment, the reimbursement of add-on-codes by traditional Medicare (and other carriers who adopt that policy) is not permitted. The AFO PA may be found in this link.
Let’s dig even deeper to understand why. The DME PDAC, the agency which validates DMEPOS, clarifies three categories of AFO. The first category 01 is custom fabricated AFO. The popular custom fabricated L1970 (free ROM Hinge AFO) and L1960 (custom solid AFO) are both produced by KevinRoot. These two examples do qualify for add-on-codes because they meet the 01 criteria. That is they are not mass produced and are produced based on a unique single patient’s negative impression, with the sole purpose of use by that one patient. Custom fabricated orthotics must also be primarily made from raw materials. L2820 (Below Knee Supplement). There are many add-on-codes permitted with custom fabricated AFO, with reimbursement based on medical necessity.
The other two categories are both prefabricated, that is they are mass produced with no one single patient in mind. These two categories are 02=custom fitted and 03=off-the-shelf. Because of this categorization, any product labeled as 02 or 03 does not qualify for reimbursement with add-on-codes. The PDAC and AFO PA all consider those products as complete as defined by their parent code.
It is also worth noting that add-on-codes also require extensive medical documentation to support their medical necessity. Should an auditor determine that the add-on-codes billed do not meet medically necessary criteria, the rejection of the add-on-code may jeopardize the integrity of the entire claim. This may result in pre-payment denial or post payment recoupment.
To summarize: At least for Traditional Fee for Service Medicare, only custom fabricated orthotics are eligible to be reimbursed with those HCPCS defined as “add-on” codes. As with their parent code, each add-on-code but be medically necessary and documented in the chart. Failure to provide proper documentation for even one add-on-code could jeopardize reimbursement for an entire claim.
Most traditional state Medicaid and Medicaid Advantage, Medicare Advantage and third-party payers utilize the traditional JA-JD coverage parameters. Check with your local carrier to determine their actual coverage guidelines.
