Refurbishment of the Richie Brace®
Medicare has always defined that the Reasonable Useful Lifetime (RUL) is 5 years for any lower extremity brace or prosthesis. Medicare will cover replacement of the AFO brace within the 5 year limit if the device “has been lost, irreparably damaged or the patient’s medical condition changes such that the current brace no longer meets the patient’s needs.”
The term “irreparable damage”, like loss or theft is considered by Medicare to be a rare, unexpected event that is an exception to the reasonable useful lifetime rule. Irreparable damage refers to a specific accident or to a natural disaster, e.g., fire, flood etc. Loss or theft of a lower extremity brace, or damage from an accident will require documentation of the exact circumstances as pre-payment audit or denial of the claim would be likely.
Irreparable damage, according to Medicare, is not the same as wear and tear from daily use. In those cases, repair but not replacement of the AFO brace would be covered by Medicare. Repair and refurbishment Medicare will reimburse the provider for the cost of replacing parts of the AFO brace, but not replacing the entire brace if it is still within 5 years of use. These parts include ankle joints, limb supports, soft interface padding, straps and external posting.
However, the plastic components of AFO braces cannot be re-formed to their original shape if they have been flattened or deformed. This is a common occurrence for many patients who are prescribed custom AFO devices. Extreme biomechanical conditions and deforming forces which require custom AFO treatment will often wear out the brace in less than 5 years of daily use. This wear most commonly results in flattening or distortion of shape of the plastic foot plate portion of the brace. When the shape or conformity of the footplate of an AFO brace has become distorted from its original shape the brace has now become irreparably damaged. Inexplicably, Medicare does not recognize that wear and tear can cause this deterioration and failure. In this case, the provider should document in the patient medical record the fact that the current brace is no longer addressing the medical condition of the patient. Most important, the practitioner should provide a narrative attached to the Medicare billing stating that the footplate has become distorted, irreparably damaged and is no longer addressing the medical needs of the patient. This documentation is mandatory as the claim for a replacement of an identical brace in less than 5 years of use will likely trigger a pre-payment audit or denial. Appeal with proper documentation, including photographs will be necessary to gain payment. Because the provider is aware that reimbursement for a replacement brace in less than 5 years is unlikely to come from Medicare, the patient should be informed and should sign an Advanced Beneficiary Notice (ABN). For further information about replacing an identical AFO brace within 5 years of original fitting, see “Medicare Same or Similar Policy: How to Avoid Denials and How to Win Appeals”, located on the Billing/Coding page of the Richie Brace® website.
Repair and refurbishment of ankle-foot orthoses
Medicare will reimburse the provider for the cost of replacing parts of the AFO brace, but not replacing the entire brace if it is still within 5 years of use. These parts include ankle joints, limb supports, soft interface padding, straps and external posting. Repairs performed less than 6 months apart will not be reimbursed.
In the case of Richie Brace® products, the straps and limb support pads (soft interface pads) will most likely require replacement within the first year of daily use of the brace by the patient. One unique feature of the Richie Brace® devices is the fact that the straps and pads are easily replaced by the practitioner in the office setting, using a “kit” provided by the Richie Brace® distributor company. This kit contains two narrow front Velcro straps, one wider back Velcro strap and two limb support pads. No rivots or glue are required for replacing these component parts and the process for installing the straps and pads is quick and simple.
Coding and billing for repairs of the Richie Brace®
The practitioner can bill for replacement of components of the ankle-foot orthosis. While this replacement of component parts is considered a “repair” of the brace, the need for replacement must be documented in the patient’s medical record. Also, the details justifying the medically necessary should also be documented.
The billing codes for these replacement parts are the following:
Replacement Straps: Use code L 4002 RB Suggested fee: $40
Soft Interface: Use code L 2820 RB
Medicare Reimbursement 2022 for L 2820: Floor $85 Ceiling $114
Note: RB modifier is used when billing for replacement parts. Also, only one code per part is used even though there are three straps and two pads. Therefore, when replacing 2 Straps and 2 Pads, bill code L 4002 once and L 2820 once.
Extensive repairs and refurbishment
Replacement of ankle joints, plastic limb supports, top covers and Arch Suspenders must be done by an authorized Richie Brace lab distributor. These repairs should be billed to Medicare and will qualify for reimbursement up the full value of the original brace. Repairs performed less than 6 months apart will not be reimbursed.
Whether performed by the provider in the office or by the distributor, the provider may bill Medicare for the services. If the replacement parts have distinct HCPCS codes as described above for straps and soft interfaces, use those codes when billing Medicare for replacement of those particular parts. In addition, replacement of the Tamarack® hinges on Dynamic Assist braces can be billed with code L 2210 RB. Since there are two hinges, the code is billed twice.
For all other parts and components which are replaced and refurbished, Medicare designates two codes which can be used for billing of repairs to a DME device:
L4205 - repair of orthotic device, labor component, per 15 minutes
L4210 - repair of orthotic device, repair or replace minor parts
The Richie Brace® authorized distributor will issue an invoice for the repair/refurbishment which will itemize the labor charges ( billed using code L 4205) as well as the parts and materials cost ( billed using code L 4210). The only exception is billing for replacement straps, soft interface and Tamarack ankle joints which have their own distinct HCPCS L-codes. For replacement of those parts, use the respective distinct codes as described above.
When billing Medicare or third-party insurance, always add a narrative to the claim documenting the reason for the repair. The ongoing medical necessity of the AFO brace should be described in detail in the patient medical record.
Medicare will pay for multiple repairs and refurbishment of a single ankle-foot orthosis over a 5-year period, for an amount up to but not exceeding the full replacement cost of the device. Also, repairs performed less than 6 months apart will not be reimbursed.
The Medicare repair policy for AFO braces is straightforward and providers can expect payment if the guidelines are followed. A point of contention, however, is the situation where the plastic footplate of the AFO brace has flattened or has lost its original shape. This damage cannot be repaired, yet is the result of wear and tear according to Medicare policy. That same policy stipulates that Medicare will pay for replacement of an AFO brace which has become irreparably damaged. In this case, the practitioner should document the irreparable damage and should be prepared to appeal denial of the claim submitted for the replacement brace if it is provided within 5 years of the original brace.