Category: Medicare

HCPCS codes L4360, L4361, L4386 and L4387 describe an ankle-foot orthosis commonly referred to as a walking boot. Walking boots that are used to provide immobilization as treatment for an orthopedic condition or following orthopedic surgery are eligible for coverage under the Brace benefit. When walking boots are used primarily to relieve pressure, especially on the sole of the foot, or are used for patients with foot ulcers, they are noncovered – no benefit category. Medicare covers therapeutic shoes, as described in the Therapeutic Shoes for Persons with Diabetes local coverage determination (LCD), for the prevention and treatment of diabetic foot ulcers.

Suppliers must add a GY modifier to HCPCS code L4360, L4361, L4386 or L4387 if the walking boot is only being used for the treatment or prevention of a foot ulcer. The absence of a GY modifier indicates that the walking boot is being used as part of the treatment for an orthopedic condition or following orthopedic surgery. Claims for HCPCS code L4360, L4361, L4386 or L4387 with a GY modifier will be denied as noncovered.  Please click here for entire announcement.

Today CMS posted its quarterly HCPCS update, which includes the following two new off-the-shelf (OTS) knee orthosis codes, effective October 1, 2014:

K0901    KO Single Upright Pre OTS             Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

K0902    KO Double Upright Pre OTS           Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

These new codes are the OTS versions of L1843 and L1845 respectively, and join the 23 other OTS codes that CMS established as part of the 2014 HCPCS update.  This means that if a product currently coded L843 or L1845 requires only minimal self-adjustment for fitting at the time of the delivery, these new OTS “K” codes are the ones that should be billed to the DME MACs.

The updated fee schedule can be accessed here:  http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS_Quarterly_Update.html

A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) and has one of the diagnoses listed in the ICD-9 Diagnosis Codes That Support Medical Necessity Group 2 Codes section.   To read the entire revision please click  REVISED LCD KNEE

As part of the enhanced enrollment screening provisions contained in the Affordable Care Act the Centers for Medicare & Medicaid Services (CMS) is implementing fingerprint-based background checks. The fingerprint-based background checks will be used to detect bad actors who are attempting to enroll in the Medicare program and to remove those currently enrolled. Once fully implemented, the fingerprint-based background check will be completed on all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls under the high risk category. For more information please click here MLN Matters