How do you know which HCPCS code to bill for an AFO Custom Fit or OTS
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How do you know which HCPCS code to bill for an AFO, if there are two codes which Medicare has provided for it?
Part 1: This is an interesting question, which often comes down to only one issue:
What did the supplier (that’s you) do at the time of delivery and fitting (when you dispensed the device) and at that time did you (the supplier) have the expertise to do so. The table below which is copied from the Medicare AFO Policy Article lists in column I AFO codes which are “custom fitted by an orthotist or someone with expertise to do so, whereas Column II codes are termed “Off-the-Shelf” and subject to minimal self-adjustment regulations (to be explained in a later paragraph). Several of these devices are offered by KevinRoot Medical and are validated by the Price Data Analysis Contractor (PDAC), the Medicare contractor which validates DME.
The above are all prefabricated orthotics. That is they are mass produced with no single one patient in mind. As was noted previously, the answer to which code is billed is dependent on what is done by the supplier at the time of delivery. To determine whether one understands two basic concepts.
Below is a workflow table from PDAC followed by some explanations:
How to Decide What Code Type for Prefabricated Orthotic
Minimal self-adjustment: This is loosely defined by Medicare as an adjustment that a caretaker, patient or relative can perform on an orthotic and does not qualify as needing a professional with expertise to perform. An example is shortening or lengthening a strap on a Cam boot, does not require undergraduate medical training and a three-year residency. The patient or care giver can make these adjustments.
What is custom fitted? It is a prefabricated orthotic requiring these three criteria:
- The person performing the “fitting” measures must be qualified and trained to do so. Examples are a physician (MD/DO/DPM) orthotist, pedorthist, etc.
- The measures performed must include trimming, bending, heating, drilling, etc. or assembling multiple parts from a kit, (e.g., after measuring one component).
- The above must be done at the time of delivery.
In the next article we will present two coding scenarios for KevinRoot prefabricated AFO and by asking questions steer you into the correct HCPCS code for your situation.
