AFO/KAFO Policy & Medical Necessity Requirements
Medical Providers,This documentation guide was created to summarize the documentation requirementsmost insurance companies look for in the medical records to justify payment for aprescribed orthosis or prosthesis. It is not inclusive of all rules and documentationrequirements. Some documentation requirements are obscure or rarely referred to. Wehave extracted the most commonly prescribed devices and tried to provide a simple,easy to follow guide of the required documentation in an effort to streamline theprovision of our services. Undoubtedly this will be more efficient for you and your officestaff. Most importantly it will mean your patient can be treated promptly.To view Center for Medicare & Medicaid Services (CMS) LCD's (local coveragedetermination) for the complete documentation requirements, you can visit our websiteand the physician tab atwww.northerncare.comIn the case of patient's needing a more comprehensive evaluation and rehabilitationplan, please refer them to Kalispell Regional Hospital's Department of Physical Medicineand Rehabilitation (PM&R ph.406-758-7035). We participate in a bimonthlymultidisciplinary prosthetic and orthotic clinic to establish a comprehensiverehabilitation plan for your patient. A physiatrist, physical therapist, and prosthetist/orthotist are present during these monthly clinics.Sincerely,Your friends at Northern Care Inc.
NORTHERN CARE, INC. PROSTHETICS & ORTHOTICSDoug Jack, CPOStan Gautier, CPOTanner Claridge, CPOAFO/KAFO Policy & Medical Necessity Requirements1. Patient must have a face-to-face visit with MD, DO, PA, DPM, NP, or CNS and an exam for the devicemust be performed.2. Patient’s medical record must say why the device is medically necessary and include ICD-10 code.3. Prescribe the device (length of need on prescription), signed and dated on or after face-to-face visitwith patient.Medical records & prescription must clearly state prefabricated or custom.If an orthosis needs to be replaced, the medical record must clearly state the problem with the existing orthosis.AMBULATORY AFO1) Specify in detail the weakness or deformity of the foot & ankle and document the patient is ambulatory and requiresstabilizationa) Perform manual muscle test & summarize which muscle groups are weak:i) Plantarflexorsii) Dorsiflexorsiii) Invertorsiv) Evertors OR b) Summarize the deformity:i) Ankle varusii) Ankle valgus2) Specify in detail how the patient will benefit functionally3) Medical record must specify prefabricated or custom AFOIf custom, at least one of the following custom criteria listed must be documented in detail:a) Unable to be fit with a prefab; or,b) Expected use is permanent or more than 6 months; or,c) Need to control the knee, ankle or foot in more than one plane; or,d) Has a neurological, circulatory, or orthopedic condition requiring custom fabricated over a model to preventtissue injury; or,e) Has a healing fracture which lacks normal anatomical integrity or proportionsAMBULATORY KAFO1) Patient must have documented weakness or deformity of the ankle (documented as above for AFO) and haveweakness or joint instability of the kneea) Perform manual muscle test of knee & summarize which muscle groups are weak:i) Knee flexors (hamstrings)ii) Knee extensors (quadriceps) OR b) Summarize joint instability of the knee:i) Knee hyperextensionii) Objective description of joint laxity (eg. varus/valgus instability, anterior/posterior drawer test, etc.)--See reverse for Non-Ambulatory AFO guidelines-210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
NON AMBULATORY AFO (static or dynamic positional)Criteria 1-4 or 5 must be met & documented:1.2.3.4.5.Non-fixed plantar flexion contracture, andReasonable expectation of the ability to correct the contracture; andContracture interferes with functional abilities, andUsed as a component of a therapy program which includes active stretching of involved muscles & tendons; OR,Has plantar fasciitis (diagnosis: M72.2)NON COVERED AFOsAFOs are not covered when used solely for the prevention or treatment of a heel pressure ulcer. Foot drop/recumbentpositioning device & static/dynamic AFO fall under this rule.To View the full CMS Local Coverage Determination (LCD), please visit our website: www.northerncare.com/afo210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
NORTHERN CARE, INC. PROSTHETICS & ORTHOTICSDoug Jack, CPOStan Gautier, CPOTanner Claridge, CPOKO Policy & Medical Necessity Requirements1. Patient must have a face-to-face visit with MD, DO, PA, DPM, NP, or CNS and an exam for the devicemust be performed.2. Patient’s medical record must say why the device is medically necessary and include ICD-10 code.3. Prescribe the device (length of need on prescription), signed and dated on or after face-to-face visitwith patient.Medical records & prescription must clearly state prefabricated or custom.If an orthosis needs to be replaced, the medical record must clearly state the problem with the existing orthosis.Prefabricated Ligament and Unloader Knee Braces1) Patient has had a recent injury to OR a surgical procedure on the knee OR is ambulatory2) Knee instability must be documented by examination of the patient and objective description of joint laxityExamples may include, but are not limited to:a) Lachman’s Testb) Anterior/Posterior Drawer Testc) Varus/Valgus instability3) Group 4 diagnosis codes are required. Visit www.northerncare.com/knee-orthosis for a list of these codes.Custom Fabricated Ligament and Unloader Knee Braces1) Patient is unable to be fit with a prefabricated brace2) Meets the requirements listed under Prefabricated Knee Braces (above)3) Has one of the following conditions (documented in detail):a) Deformity of the leg or knee (varum or valgum)b) Calf/thigh disproportionatec) Minimal muscle mass upon which to suspend brace“Post Op” Range of Motion Knee Braces1) Patient has had a recent injury OR surgical procedure2) Dictate specific range of motion degrees to set the brace3) Group 2 diagnosis codes are required. Visit www.northerncare.com/knee-orthosis for a list of these codes.To View the CMS Local Coverage Determination (LCD), please visit our website: www.northerncare.com/knee-orthosis210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
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NORTHERN CARE, INC. PROSTHETICS & ORTHOTICSDoug Jack, CPOStan Gautier, CPOTanner Claridge, CPOSpinal Orthosis (TLSO & LSO) Policy &Medical Necessity Requirements1. Patient must have a face-to-face visit with MD, DO, PA, DPM, or NP, and an exam for the device must beperformed.2. Patient’s medical record must say why the device is medically necessary and include ICD-10 code.3. Prescribe the device (length of need on prescription), signed and dated on or after face-to-face visit withpatient.Medical records & prescription must clearly state prefabricated or custom.If an orthosis needs to be replaced, the medical record must clearly state the problem with the existing orthosis.NON-ELASTIC SPINAL BRACES1) Non-Elastic Spinal Braces are a covered service. Please document one or more of the following in the patient’smedical record.Brace is needed to:a) Reduce pain by restricting mobility of the trunk; or,b) Facilitate healing following an injury to the spine or related soft tissues; or,c) Facilitate healing following a surgical procedure on the spine or related soft tissue; or,d) Otherwise support weak spinal muscles and/or deformed spine2) Please also include the following information to help best assess the patient’s needs:a) ICD10/Diagnosisb) Level & Type of fracturec) What type of motion restraint is required:i) Lateral flexion (coronal plane)ii) Anterior flexion and/or posterior extension (sagittal plane)iii) Axial rotation (transverse plane)iv) OR a combination that stabilizes in all three planes (triplanar stabilization)3) If a custom fabricated brace is needed, please document why a prefabricated brace would not be effective.To View the full CMS Local Coverage Determination (LCD), please visit our website: www.northerncare.com/spinal*If the patient is following up with you after a stay at KRMC or NV and obtained a b race during their stay which does not fitwell, please document what is wrong with their current brace and why it is not effective.--- Please see the back for Adult and Pediatric Scoliosis Requirements --210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
SCOLIOSIS BRACESAdult Scoliosis Orthosis (ASO)1) Is the length of need indefinite or permanent?2) Describe the curvature3) Document the goal of the ASOa)Stabilize the spineb)Reduce painc)Reduce the curvature progression4) If custom, please state custom is needed due to a significant deformityCustom shaped foamhelps to separate theribs from the hip3 Velcro strap closuresmake it easy to readjustduring the day for more orless support based on theperson’s activity levelPediatric Scoliosis1) Type of Scoliosis: Idiopathic, congenital, neuromuscular2) Curve magnitude (in degrees)3) Location (segments of the spine)4) Direction of the curve(s): left/right5) Document the progression of curves6) Goal of treatmenta)Stop or minimize curve progressionb)Avoid surgeryc)Reduce pain**We highly recommend scoliosis-based physical therapy in conjunction with bracing.210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
NORTHERN CARE, INC. PROSTHETICS & ORTHOTICSDoug Jack, CPOStan Gautier, CPOTanner Claridge, CPOLower Limb Prosthesis Policy &Medical Necessity Requirements1. Patient must have a face-to-face visit with MD, DO, PA, DPM, NP, or CNS and an exam for the devicemust be performed.2. Patient’s medical record must say why the device is medically necessary and include ICD-10 code.3. Prescribe the device, signed and dated on or after face-to-face visit with patient.Due to the documentation needs and wide scope of the necessary prosthetic evaluation, please considerreferring your patient to the KRMC Department of Physical Medicine and Rehabilitation’s bi-monthlyProsthetics and Orthotics clinic. At this appointment, your patient will be evaluated for their prosthetic needsby a Physiatrist or PA, Physical Therapist, and Prosthetist. We’ve seen the best success when using thismultidisciplinary approach for the patient’s prosthetic care. PHONE: 406-758-7035.If you would prefer to do the prosthetic evaluation, please document the following:1. Present condition and past medical history that’s relevant to functional deficits2. Desire to ambulate3. Symptoms limiting ambulation or dexterity4. Diagnosis causing these symptoms5. Other comorbidities causing ambulatory problems or impacting the use of a new prosthesis6. What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used (either in addition to theprosthesis or prior to amputation)7. Description of activities of daily living and how impacted by deficit(s)8. Physical examination that is relevant to functional deficits9. Weight and height, including any recent weight loss/gain10. Cardiopulmonary examination11. Musculoskeletal examination- Arm and leg strength and range of motion12. Neurological examination- Gait- Balance and Coordination--- See reverse side for Functional Levels and Repairs, Replacements, Supplies Information --210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
FUNCTIONAL LEVEL (K0-K4)Patient’s functional capabilities are crucial to establishing medical necessity for a prosthetic device. Components (knees,ankles, feet) are restricted to specific functional levels. Functional capabilities must be thoroughly documented, both beforeand after amputation. Rehabilitation potential must be based on the following classification levels:a. Level K0: Doesn’t have ability or potential to ambulate or transfer safely; prosthesis does not enhancequality of lifeb. Level K1: Has ability or potential to use prosthesis for transfer or ambulation on level surfaces at fixedcadence (household ambulator)c. Level K2: Has ability or potential for ambulation with ability to traverse low level environmental barriers suchas curbs, stairs or uneven surfaces (limited community ambulatory)d. Level K3: Has ability or potential for ambulation with variable cadence. Community ambulatory who hasability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activitythat demands prosthetic utilization beyond simple locomotion.e. Level K4: Has ability or potential for ambulation that exceeds basic ambulation skills, exhibiting high impact,stress, or energy levels. (demands of a child, active adult, or athlete)* It is recognized that bilateral amputees often cannot be strictly bound by Functional K-Level.Please list any activities and environmental barriers (stairs, curbs, uneven terrain, etc ) that do or do not requirethe patient to ambulate at a variable cadence.Repairs, Replacements, Supplies needed for prosthesis1) If Northern Care furnished the existing prosthesis and has a Rx on file, the documentation needs are:a. Socks/Sheaths/Shrinkers: Please have the patient call our office.b. Gel Interface Liners, Suspension Sleeves, or Minor Parts: A phone encounter is all that is needed. Dictatewhat the new supply is, why the new supply is needed, and what is wrong with the current one. Ex: torn,broken, worn, etc.c. Major Components (Socket, Knee, Foot): A face to face visit and evaluation is needed to document what iswrong with the current component.2) If prosthesis was furnished elsewhere and Northern Care has no Rx on file, please see the patient for a face to facevisit and clearly document what is wrong with their current prosthesis and what supplies they need and why. A shorthistory of their current prosthesis is needed that should include, but is not limited to:a.Amputation historyb.ADL’s that the prosthesis helps with. Example: for a K1 ambulator this may only include transfers, butfor a K3 this may mean cutting wood or mowing the lawn.c.Continued need for the prosthesisTo View the CMS Local Coverage Determination (LCD), please visit our website: www.northerncare.com210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755-6322 FAX (406) 755-6324Feb 20 2018
NORTHERN CARE, INC. PROSTHETICS & ORTHOTICSDoug Jack, CPOStan Gautier, CPOTanner Claridge, CPOCranial Remolding Helmets for Plagiocephaly/BrachycephalyHelmet Therapy is most effective between the ages of 3 – 8 months of age. Our officeis happy to see younger patients to get base measurements to see if repositioning issuccessful. The sooner the baby is evaluated the better.Repositioning and Tummy TimeALL insurances require a minimum of 2 months of documented attempts atrepositioning (Pediatrician or Therapist directed).Ex: If you notice a flat spot forming at the patient’s 2mth WCC, dictate thedeformity and instruct the parents on repositioning OR, preferably, recommendPhysical Therapy. This may include, repositioning the infant during diaper changesand resting periods. At the 4mth WCC reevaluate and refer to Northern Care ifneeded.Approved or Associated ICD10 Codes: Q67.3, Q67.4, Q75.0, Q75.9MT Medicaid Requirements1. Must document moderate to severe deformational or positional plagiocephaly by physical examination.2. Must document a continued deformity after at least TWO MONTHS of parent or caregiver education and at leasttwo months of physical or occupational therapy.Ages 0-6 months: Criteria #1 and #2 must be met.Ages 6 months and up: Only Criteria #1 must be met.‐‐‐ See reverse side for HMK Foot Orthotics Policy ‐‐‐210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755‐6322 FAX (406) 755‐6322Feb 20 2018
Foot Orthotics for Pediatric PatientsFoot orthotics are not generally a covered service for most insurance companies. Medicare views them as a noncoveredservices and they are an out of pocket cost to patients. However, MT Medicaid does have a policy that states orthotics are abillable service for eligible children under the age of 21.According to the Montana Healthcare Programs Notice: Durable Medical Equipment from April 27, 2015:Devices and instruments to help a child maintain his or her level of mobility, correct physical issues, or decrease pain shouldbe considered when prescribed by their medical provider and the following condition(s) apply. This list is not all-inclusive,and each case is determined on a case-by-case review of medical necessity: Knee or hip subluxation, dislocation;Spastic movement;Correct, limit or prevent deformities;Low-tone pronation (fallen arches, outward-turned foot due to muscle weakness);High-tone pronation (high arch, outward-turned foot due to increased muscle tone);Swing-phase inconsistency (erratic movements in the foot);Drop-foot (drop of the front of the foot due to weakness);Eversion (outward turn); orInversion (inward turn).If the child is not having symptoms or pain associated with the above conditions, foot orthotics are not consideredmedically necessary.210 WINDWARD WAY KALISPELL, MT 59901 PHONE (406) 755‐6322 FAX (406) 755‐6322Feb 20 2018
Custom Fabricated Ligament and Unloader Knee Braces 1) Patient is unable to be fit with a prefabricated brace 2) Meets the requirements listed under Prefabricated Knee Braces (above) 3) Has one of the following conditions (documented in detail): a) Deformity of the leg or knee
Preemie AFO Pair and Bar Ponseti AFO Pair, sizes 0 000-12 Ponseti AFO Pair, sizes 0 000-6 Ponseti AFO Pair with To e Stilt, sizes 2-11 Ponseti AFO/PFS Pair, siz es 00-12 Ponseti AFO/PFS Pair with Toe Stilt, sz 2-11 Ponseti Extra Short Bar Ponseti Short Bar Ponset
manual that comes with the AFO and/or the physical therapist/doctor will provide the instructions for use and wearing schedule. Keeping the equipment clean Use a mild soap and a soft damp cloth to clean the entire surface of the AFO. Then allow the AFO
Charleston Dress Orthotic (Carbon Fiber) 105 Custom Toe Filler with Carbon Plate 150 Charleston Supra-Mo Wrap 250 Charleston AFO 300 Charleston Assist AFO 375 (Dorsiflexion assist joints) Solid Ankle Arizona AFO (Ankle Gauntlet) 450
Ankle-foot orthotic (AFO), multiligamentus ankle support, prefabricated, includes fitting and adjustment : L1907 . Ankle-foot orthotic (AFO), supramalleolar with straps, with or without interface/pads, custom fabricated : L1910 . Ankle-foot orthotic (AFO), posterior, single bar,
7. What is medical necessity and what tool can you refer to for the medical necessity of a service? Answer: The term "medical necessity" relates to whether a procedure or service is considered appropriate in a given circumstance. Tools to determine medical necessity include National Coverage Determinations (NCDs), Local Coverage
AFO, Ankle Foot Orthosis, Articulated (Custom-Molded) Purpose of the Device . Can be made with carbon graphite for light weight needs such as multiple sclerosis Special Considerations This design can be incorporated into a KAFO for patients with severe weakness .File Size: 1MB
The manufacturing process requires approximately 50% lesser time to develop AFO and 70% lesser time to develop KAFO compared to Brace and Limb laboratory of University Malaya. Unlike traditional approaches, the design technique facilitates exact positioning of articulated
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