Billing, Coding, & Documentation

Billing, Coding, & Documentation

November 17, 2020

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Click here to download document samples for the following:

LCD Requirements: L4396 

The Equinus Brace® is treating equinus deformity and or plantar fasciitis according to the Medicare LCD covering AFOs for Ambulatory patients. The LCD for L4396 consists of 5 requirements: A static ankle-foot orthosis (AFO) (L4396) is
covered if all of criteria 1 – 4 or criterion 5 is documented:

  1. Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); This is from the patient’s most plantarflexed position.
  2. Reasonable expectation of the ability to correct the contracture;
  3. Contracture is interfering or expected to interfere significantly with the patient’s functional abilities; 
  4. Used as a component of a therapy program, which includes active stretching of the involved muscles and or tendons.
    AND OR
  5. The patient has plantar fasciitis.

M24.571 – Contracture, Right Ankle - applies to criteria 1 - 4
M24.572 – Contracture, Left Ankle - applies to criteria 1 - 4
and or
M72.2 - Plantar Fascia Fibromatosis (including Plantar Fasciitis) - applies to criteria 5

Note on Diagnosis

When the brace is being used for any pathology that has an associated equinus deformity (i.e. Achilles Tendonitis, Posterior Tibial Tendon Dysfunction, Metatarsalgia, Pronation Syndrome, Acquired Flatfoot Deformity), the diagnosis code for ankle contracture (i.e., M24.571/M24.572) should be linked to the CPT code for the brace.

  • If the brace is being used for plantar fasciitis without an equinus deformity, it should be linked to the plantar fasciitis diagnosis code (i.e., M72.2).
  • If the brace is being used for plantar fasciitis with an ankle contracture deformity, it should be linked to plantar fasciitis (M72.2) as the primary diagnosis and ankle contracture (M24.571/M24.572) as the secondary

As always, documentation is critical, especially for the ankle contracture deformity diagnosis (M24.571/M24.572). Please note that the ICD 10 for Short Achilles Tendon Acquired (M67.01/M67.02) are not listed in the LCD for
L4396; therefore it is not recommended to utilize these codes with the CPT code for The Equinus Brace®.

Here is a sample of suggested documentation:

Ankle Joint Objective Findings Documentation

Ankle joint dorsiflexion with the knee extended was
measured with a goniometer/tractograph:
right = ___ degrees and left = ___ degrees (abnormal considered less than 5 degrees)
Ankle joint dorsiflexion with the knee flexed was measured
with a goniometer/tractograph:
right = ___ degrees and left = ___ degrees (abnormal considered
less than 10 degrees)
Total ankle joint range of motion measured with a goniometer/tractograph:
Plantarflexion: right = ___ degrees and left = ___ degrees (40 –
60 degrees = normal);
Dorsiflexion: right = ___ degrees and left = ___ degrees (10 – 20
degrees = normal)

Note on Documentation

There should also be documentation of symptoms and findings of the  associated lower extremity pathological condition (i.e., Achilles tendonitis, Posterior Tibial Tendon Dysfunction, Metatarsalgia, Pronation Syndrome, Acquired Flatfoot Deformity) in the Musculoskeletal Objection Findings

It is also important to document any prior treatment, especially manual stretching/physical therapy/shoe modifications in the History of Present Illness in the Subjective Complaint section of the note.

In the Plan section of the note, the suggested documentation for the brace is as follows.

The Equinus Brace® Fitting and Dispensing Documentation:

The plastic custom-fitted Ankle Foot Orthosis was assembled in accordance with the manufacturer’s instructions and based on the specific anatomical and physiological requirements of the patient. This device was custom-fitted by a licensed podiatrist with expertise to provide this service and dispensed for the [right, left, bilateral] foot/feet. The patient was examined while wearing the device after several fitting maneuvers of trimming, bending, shaping, etc., and the fit was found to be appropriate. Medical Necessity: Due to the pain in the
foot/ankle/leg with weight bearing throughout the day, with a diagnosis of equinus deformity and related symptoms, this is medically necessary for the treatment. The function of this device is to serve as an anti contracture device of the Gastrocsoleal complex and to restrict and limit motion and help reduce excessive stress and strain to Gastrocsoleal complex and foot/ankle/leg. It is being utilized to prevent the plantar contracture of the Gastrocsoleal complex.
The goals of this therapy  are to:

  1. Treat plantarflexion contracture of the ankle with dorsiflexion, the ankle on passive range of motion testing is noted to have at least 10 degrees (i.e., a non-fixed contracture); 
  2. Provide a reasonable expectation of the ability to correct the contracture; 
  3. Reduce the contracture that is interfering or expected to interfere significantly with the beneficiary’s functional abilities;
  4. Used as a component of a therapy program which includes active stretching of the involved muscles and or tendons;
    AND OR
  5. Treat the beneficiary’s plantar fasciitis.
Additionally, medial and lateral ankle dorsiflex assistive and plantarflex restraint

hinges are included on the brace and were set at [__] degrees of dorsiflexion. These will be periodically adjusted based on future physical examination of the patient’s progress.

Additional Video: Adjusting the Pediatric Brace

Instructions and Goals for the patient:

  • The device will be utilized for the next 8 to 12 weeks.
  • The intent of these hinges is to resist plantarflexion and assist with dorsiflexion of the Gastrocsoleal complex and or plantar fascia. These hinges will be adjusted over the course of the patient’s therapy. The patient was instructed not to adjust the hinges. They were also advised to bring the device to the office at their next visit for further evaluation and adjustments.
  • The goals and function of this device were explained in detail to the patient.
  • The patient states that the device is comfortable when applied. The patient was shown and told in detail how to properly apply, remove, wear, and care for the device. The patient was able to apply and remove the device properly without assistance and to not ambulate with the device in place.
  • The device was then dispensed and was suitable for the condition and not substandard. No guarantees regarding the resolution of symptoms were given, and precautions were reviewed.
  • Written instructions and warranty information were given along with the list of the current Durable Medical Equipment Supplier Standards. The patient signed a written proof of delivery. All questions were answered to their satisfaction. The patient also received a copy of our Complaint Protocol and was provided a follow-up appointment for two weeks.

When billing for the The Equinus Brace® the following is suggested.

L4396 - KX: Medical Documentation Supports the Medical Policy for AFO

  • RT, LT (if using bilateral both RT, LT modifiers must be included).
  • However, it is important to note that it is best that they are billed separately i.e., L4396 KX RT billed as 1 unit and L4396 KXLT billed as 1 unit. This helps to ensure accurate payment is made on both.

L2210 - RT, LT EXCEPT for MEDICARE/GOVERNMENTAL PLANS (The Equinus Brace® is currently appealing this code with Medicare, this code may continue to be billed with non-governmental insurance providers).

  • If using bilaterally, both RT, LT modifiers must be included AND the number of units per side (i.e., 2 per side as Equinus Brace® has two hinges per brace).
  • It is important to note that it is best that each “pair” of hinges are billed separately i.e., L2210 RT billed as two units, and L2210 LT billed as two units. This helps to ensure accurate payment is made on all four hinges.
Disclaimer: The final and sole responsibility for the correct coding within established laws, rules, and standards of practice rests upon the party submitting the claim.

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