Dx. Specific DME Protocols MPMA Summer Meeting

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Dx. Specific DME ProtocolsMPMA Summer Meeting

• Hal Ornstein, DPM, FACFAS
• Chairman, AAPPM
• 18 Years in Private Practice
• President of the
• Jeff Frederick Fan Club

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REASONS TO FOLLOW THESE PROTOCOLS

• Improved outcomes
• Easy to follow
• Medico-legal security
• Improved patient compliance
• Improved patient satisfaction
• Patient convenience
• Ease of inventorying
• Consistent with standards of care

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Documentation Summary, Chart

• Prescription or order
• Documentation of Therapeutic Necessity
• Signed Certification of Patient Receipt
• Chart Notes of Dispense
• Invoice

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Documentation Summary, Office

• Complaint Resolution Policy, Forms, Log
• Supplier Standards
• Warrantee Info
• Posted hours

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DME Codes

• L2999 Non covered
• L1902 AFO gauntlet style
• L1906 AFO multiligamentous
• L4386 AFO non-pneumatic walking
• L4396 AFO plantar fascia night splint
• L4360 AFO pneumatic below knee
• L1971 AFO with ankle joint
• L4350 AFO ankle control orthosis
• L1932 AFO dynamic
• L1951 AFO spiral, plastic, other

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DME Codes

• L1940, L2210, L2330, L2820
• Arizona AFO, dynamic assist
• L1970, L2210, L2820
• Richie AFO, dynamic assist
• L1940, L2330, L2820
• Arizona AFO, standard
• L1970, L2820b
• Richie AFO
• L1940, L2330, L2820
• Arizona AFO, tall
• L1960, L2340, L2820
• Arizona AFO extended
• A5501, A5506, A5503
• Custom molded shoes with rocker bottoms and
  offset heels
• L1940, L2330, L2820, A5501, A5506, A5503
• Custom molded shoe with Arizona Standard AFO

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Plantar Fasciitis

• 728.71 Plantar fascial fibromatosis
• 718.47 Plantarflexion contracture of ankle

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Plantar fasciitis Initial Visit
PowerStep Insert Suggested Code L2999 Patient
Pays
Aircast Airheel Suggested Code L2999 Patient Pays
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Plantar fasciitis Subsequent Visit
Mild
Ossur Exoform
Ossur Formfit
Ossur Airform
Night Splint, posterior or dorsal Suggested
Code L4396 DMEPOS Fee Ceiling 180
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Plantar fasciitis Subsequent Visit
Severe
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Posterior Tibialis Tendonitis

• 726.72 Tibialis tendonitis
• 905.8 Late effect of tendon injury, sprain,
  strain

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Posterior Tibialis Tendonitis, Mild Initial
Visit
Aircast Airlift PTTD Suggested Code L1906 DMEPOS
Fee Ceiling 135
PowerStep Insert Suggested Code L2999 Patient
Pays
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Posterior Tibialis Tendonitis, Moderate Initial
Visit
Donjoy Velocity ES Suggested Code L1971 DMEPOS
Fee Ceiling 505
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Posterior Tibial Tendonitis Severe, Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Posterior Tibialis Strain, Moderate Subsequent
Visit
Ossur Exoform
Ossur Formfit
Ossur Airform
Night Splint, posterior or dorsal Suggested
Code L4396 DMEPOS Fee Ceiling 180
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Posterior Tibialis, Rupture, Stage 3

• 727.68 Rupture, tendon of foot and ankle,
  non- traumatic
• 728.4 Laxity of ligament
• 734 Flat foot, acquired

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Posterior Tibialis Strain, Rupture, Stage 3
Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Posterior Tibialis Strain, Rupture, Stage 3
Subsequent Visit, if getting better
Less Severe
More Severe
Donjoy Velocity ES Suggested Code L1971 DMEPOS
Fee Ceiling 505
Aircast Airlift PTTD Suggested Code L1906 DMEPOS
Fee Ceiling 135
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Posterior Tibialis Strain, Rupture, Stage 3
Subsequent Visit, if getting worse
Richie AFO Suggested Code L1970, L2820 DMEPOS
Fee Ceiling 901
Arizona AFO Suggested Code L1940, L2330,
L2820 DMEPOS Fee Ceiling 1099
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Ankle Sprain, Grade 1

• 845.02 Sprain and strain of ankle and foot,
  calcaneofibular
• 845.00 Sprain and strain of ankle and foot,
  unspecified site
• 729.5 Pain in limb
• 719.07 Unspecified disorder of ankle and foot

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Ankle Sprain, Grade 1 Initial Visit
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
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Ankle Sprain, Grade 2, 3

• 729.5 Ankle pain and support
• 719.07 Effusion of joint, ankle, foot
• 845.02 Sprain and strain of ankle and foot,
  calcaneofibular
• 845.01 Sprain and strain of ankle and foot,
  deltoid ligament
• 824.2 Ankle fracture, lateral malleolus only
• 824.6 Ankle fracture, trimalleolar

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Ankle Sprain, Grade 2, 3 Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Ankle Sprain, Grade 2, 3 Follow up visit, 2 - 6
weeks
Delayed Healing
Healing Well
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
Donjoy Velocity ES Suggested Code L1971 DMEPOS
Fee Ceiling 505
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Pediatric Fracture

• 729.5 Ankle pain and support
• 719.07 Unspecified disorder of ankle and foot
• 845.02 Sprain and strain of ankle and foot,
  calcaneofibular
• 845.01 Sprain and strain of ankle and foot,
  deltoid ligament
• 824.2 Ankle fracture, lateral malleolus only
• 824.6 Ankle fracture, trimalleolar

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Pediatric Fracture Initial Visit
Aircast SP Walker
Aircast XP Walker
Pneumatic Walker, Pediatric Size Suggested
Code L4360 DMEPOS Fee Ceiling 312
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Pediatric Fracture Follow up visit, 7 - 9 weeks
Aircast Air-Stirrup, pediatric size Suggested
Code L4350 DMEPOS Fee Ceiling 100
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Ankle Instability

• 845.02 Sprain and strain of ankle and foot,
  calcaneofibular
• 845.00 Sprain and strain of ankle and foot,
  unspecified

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Ankle Instability Initial Visit
Moderate
Mild
Donjoy Velocity ES Suggested Code L1971 DMEPOS
Fee Ceiling 505
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
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Tarsal Tunnel Syndrome

• 355.5 Tarsal tunnel syndrome
• 719.47 Pain in joint, ankle, foot

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Tarsal Tunnel Syndrome Initial Visit
Mild
Moderate
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
Donjoy Velocity ES Suggested Code L1971 DMEPOS
Fee Ceiling 505
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Tarsal Tunnel Syndrome, severe Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Peroneal Tendonitis

• ????
• ?????

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Peroneal Tendonitis Initial Visit
Mild, Moderate
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
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Peroneal Tendonitis, severe Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Peroneal Tendonitis Subsequent Visit
Severe
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
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Sinus Tarsi Syndrome

• 726.79 Enthesopathy of ankle and tarsus, other
• 719.47 Pain in joint, ankle, foot

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Sinus Tarsi Syndrome Initial Visit
Mild
Moderate
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
Donjoy Velocity ES Suggested Code L1971 DMEPOS
Fee Ceiling 505
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Sinus Tarsi Syndrome Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Severe Sinus Tarsi Syndrome Subsequent Visit
Ossur Gameday Suggested Code L1906 DMEPOS Fee
Ceiling 135
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Drop Foot

• 736.79 Acquired deformity of foot and ankle
• 438.20 Hemiplegia
• 719.97 Joint derangement, ankle and foot
• 356.1 Peroneal muscle atrophy, Charcot Marie
  Tooth disease
• 340 Multiple sclerosis
• 138 Poliomyelitis, late effects
• 728.85 Spasm of muscle

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Flaccid Drop Foot Initial Visit
Ossur Dynamic Suggested Code L1951 DMEPOS Fee
Ceiling 905
Euro International Peromax Suggested
Code L1932 DMEPOS Fee Ceiling 962
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Spastic Drop Foot Initial Visit
Richie Dynamic Assist Suggested Code L1970,
L2210, L2820 DMEPOS Fee Ceiling 976
Arizona Dorsiflex Assist Suggested Code L1940,
L2210, L2330, L2820 DMEPOS Fee Ceiling 1174
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Rigid Equinovarus

• 736.71 Equinovarus, acquired
• 754.51 Equinovarus, congenital
• 728.85 Spasm of muscle

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Rigid Equinovarus Initial Visit
Arizona AFO, Tall, foot plate to sulcus Suggested
Code L1940, L2330, L2820 DMEPOS Fee
Ceiling 1099
Arizona AFO, Extended Suggested Code L1960,
L2330, L2820 DMEPOS Fee Ceiling 1179
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Achilles Tendonitis, Achilles Tendon Tear

• 845.09 Achilles tendon strain, tear
• 726.71 Achilles tendonitis

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Achilles Tendonitis, Achilles Tendon Tear
Initial Visit
Ossur Equalizer Premium
Ossur Equalizer Low Top
Aircast SP Walker
Aircast FP Walker
Pneumatic Walker Suggested Code L4360 DMEPOS Fee
Ceiling 312
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Achilles Tendonitis, Achilles Tendon Tear Second
visit
Ossur Airform
Ossur Exoform
Ossur Formfit
Night Splint, posterior or dorsal Suggested
Code L4396 DMEPOS Fee Ceiling 180
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Achilles Tendonitis, Achilles Tendon Tear Follow
up visit
Bauerfeind Achilleotrain Suggested
Code L1902 DMEPOS Fee Ceiling 90.11
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Metatarsal Fracture

• 733.10 Stress fracture, unspecified
• 825.25 Fracture of the metatarsal bone

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Metatarsal Fracture Initial visit
Darco Med-Surg Walker Suggested
Code L2999 DMEPOS Fee Ceiling Patient pays
Ossur Equalizer Low Top Walker Suggested
Code L4386 DMEPOS Fee Ceiling 171
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Metatarsal Fracture Follow up visit
PowerStep readymade orthotic Suggested
Code L2999 DMEPOS Fee Ceiling Patient pays
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Charcot, Active

• 713.5 Arthoropathy associated with
  neurological disorder
• 715.17 Osteoarthritis, localized foot and ankle

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Charcot, Active,Goals of Treatment

• Prevent further deformity
• Obtain a plantargrade foot
• Avoid excess pressure on skin

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Charcot, ActiveInitial Visit
Bledsoe Charcot Conformer Suggested
Code L4360 DMEPOS Fee Ceiling 312
Total Contact Cast, non-weight-bearing
Aircast XP Diabetic Walker Suggested
Code L4360 DMEPOS Fee Ceiling 312
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Charcot, Active,Follow-up Visit
CROW if patient non-compliant and bearing
weight Suggested Code L1960, L2340, L2820 DMEPOS
Fee Ceiling 1228
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Charcot, Static

• 715.17 Osteoarthritis, localized foot and ankle
• 735.9 Unspecified deformity of ankle and foot,
  acquired

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Charcot, Static, Treatment
AZ AFO with removable footbed and Custom mold
shoes Suggested Code L1940, L2330, L2820,
A5501, A5506, A5503 DMEPOS Fee Ceiling 1618
Custom mold shoes, offset heels and rocker
bottoms Suggested Code A5501, A5506,
A5503 DMEPOS Fee Ceiling 519
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Disclaimer
Suggested codes are based on publically available
information and are offered as a convenience to
physicians. The authors make no claims, promises
or guarantees as to the availability of
reimbursement for any of the suggested products.
It is within the sole discretion of the
physicians to determine the appropriate billing
code for a product as well as whether the use of
a product complies with medical necessity and
other documentation requirements of the payor.
The authors and the American Academy of Podiatric
Practice Management accept no responsibility
whatsoever in this regard.
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Thank You!