DME Treament Protocol

PODIATRIC PRACTICE MANAGEMENT

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DME Treatment Protocols

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Contents Plantar Fasciitis

1

Tibial Tendinitis

1

Reasons to Follow These AAPPM DME Treatment Protocols:

Achilles Tendinitis

2

1. Easy to follow

Peroneal Tendinitis

2

2. Medico-legal security

Adult Acquired Flatfoot (PTTD)

3

Ankle Sprain (Grade 1)

4

Ankle Sprain (Grade 2,3)

4

6. Consistent with standards of care

Ankle Instability

4

7. Faster, more lasting healing

Degenerative Joint Disease, Ankle, Rearfoot

5

Pediatric Fractures and Sprains

5

Tarsal Tunnel Syndrome

6

Sinus Tarsi Syndrome

6

Flaccid Drop Foot

7

Spastic Equinus

7

Rigid Equinovarus

8

Post Sx

8

Metatarsal Fractures

8

Charcot (Active)

9

Charcot (Static)

9

3. Improved patient compliance 4. Improved patient satisfaction 5. Easy of inventorying

8. Cost effectiveness For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for “reasonable and necessary� are defined by the following indications and limitations of coverage and/or medical necessity. AFOs and KAFOs used during ambulation: Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, and L4386 are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally. Knee-ankle-foot orthoses (KAFO) described by additional knee stability is required. If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not medically necessary. AFOs and KAFOs that are molded-to-patient-model, or custom-fabricated, are covered for ambulatory patients when the basic coverage criteria listed above and one of the following criteria are met: The patient could not be fit with a prefabricated AFO, or the condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six months), or There is a need to control the knee, ankle, or foot in more than one plane, or The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions. If the specific criteria for a molded-to-patient-model or customfabricated orthosis are not met, but the criteria for a prefabricated custom fitted orthosis are met, payment will be based on the allowance for the least costly medically appropriate alternative.

These recommendations are presented based on the collective input of members of the American Academy of Podiatric Practice Management. It is understood that every case is different and must be treated individually. The recommendations are made to assist practitioners with proven treatment modalities to improve patient care.

Plantar Fasciitis 728.71 Plantar fascial fibromatosis

Initial Visit

Subsequent Visit Mild

Airheel L2999 Patient pays

Protech Pro insert L2999 Patient pays

Airform Night Splint L4398 L4396 National $180Ceiling Fee $85.76

速

Body Armor Night Splint L4396 National $180 Ceiling Fee $186.30

Severe Equalizer Air Walker L4360 National $312 Ceiling Fee $322.31 Equalizer Premium Walker L4360 National $312Ceiling Fee $322.31 SP Pneumatic Walker L4360 National $312 Ceiling Fee $322.31 XP Pneumatic Walker L4360 National $312 Ceiling Fee $322.31

Tibial Tendinitis 726.72 Tibialis tendinitis 905.8 Late effect of tendon inury, sprain, strain

Initial Visit Mild Airlift PTTD L4350 L1902 $101 National$103.23 Ceiling Revised Fee $92.92

Protech Pro insert L2999 Patient pays

Moderate Rebound with Stability Strap L1951 L1906 $505 National Ceiling Fee $139.98 Velocity ES L1971 L1906 $505 National Ceiling Fee $139.98

Subsequent Visit Severe Equalizer Premium Air Walker Air Walker L4360 National $312Ceiling Fee $322.31 Equalizer Premium Walker L4360 National Ceiling Fee $322.31 $312

Airlift PTTD L4350 L1902 $101 National Fee $92.92 Revised Ceiling $103.23 Gameday L1906 Revised L1902 $135 National RevisedCeiling $92.19Fee $92.92

SP Pneumatic Walker L4360 National $312Ceiling Fee $322.31 XP Pneumatic Walker L4360 National $312Ceiling Fee $322.31

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s) and charges. Price reflect the 2010 HCPCS national ceiling. Actual reimbursement may vary.

1

Achilles Tendinitis 726.71 Achilles tendinitis 845.09 Achilles tendon sprain, strain 727.69 Achilles tendon rupture

Initial Visit

Follow up Visit

Equalizer Air Walker L4360 National Ceiling Fee $322.31 $312

Achilleotrain Patient pays

SP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312 XP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312

Peroneal Tendinitis 726.79 Peroneal Tendinitis

Initial Visit Mild to Moderate Gameday L1906 Revised L1902 $135 National Ceiling Fee $92.92 Revised $92.19

Subsequent Visit

Severe Equalizer Air Walker L4360 $312 Ceiling Fee $322.31 National SP Pneumatic Walker L4360 $312 Ceiling Fee $322.31 National XP Pneumatic Walker L4360 $312 Ceiling Fee $322.31 National

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s). Price reflect the 2009 DMEPOS national ceiling. Actual reimbursement may vary.

2

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Mild to Moderate Gameday L1906 Revised L1902 $135 Revised $92.19 National Ceiling Fee $92.92

Adult Acquired Flatfoot (PTTD) 727.68 Rupture, tendon of foot and ankle, nontraumatic 736.79 Pronation ankle, foot, acquired 734 Flat foot, acquired

Initial Visit Equalizer Premium Walker L4360 National$312 Ceiling Fee $322.31 Equalizer Air Walker L4360 National Ceiling Fee $322.31 $312 SP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312

Subsequent Visit If getting better, less severe Airlift PTTD L1902 L4350 $101 National Ceiling Fee Revised $103.23 $92.92

Gameday L1906 Revised L1902 $135 National RevisedCeiling $92.19Fee

If getting better, More severe Rebound with Stability Strap L1906 L1951 National Ceiling Fee $139.98 $505

If getting Worse Arizona AFO Standard L1940, L2330, L2820 National $742Ceiling Fee $1133.81

Velocity ES L1971 L1906 National $505 Ceiling Fee $139.98

$92.92

XP Pneumatic Walker L4360 National$312 Ceiling Fee $322.31

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s) and charges. Price reflect the 2010 HCPCS national ceiling. Actual reimbursement may vary.

3

Ankle Sprain Code (Grade 1) 729.5 Ankle pain and support 719.07 Effusion of joint, ankle, foot

Ankle Instability

Initial Visit

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

Initial Visit

$139.98

Velocity ES L1906 L1971 $505 Ceiling Fee National

824.2 Ankle fracture, lateral malleolus only 824.6 Ankle fracture, trimalleolar

Equalizer Air Walker L4360 National $312Ceiling Fee $322.31 Equalizer Premium Walker L4360 National $312 Ceiling Fee $322.31

Subsequent Visit healing well Gameday L1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

SP Pneumatic Walker L4360 National $312Ceiling Fee $322.31 XP Pneumatic Walker L4360 $312 Ceiling Fee $322.31 National

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s). Price reflect the 2009 DMEPOS national ceiling. Actual reimbursement may vary.

4

Rebound L1906 L1951 National Ceiling Fee $505

$139.98

Ankle Sprain (Grade 2,3) 729.5 Pain in limb

Gameday L1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

845.02 Sprain and strain of ankle and foot, calcaneofibular

845.02 Sprain and strain of ankle and foot, calcaneofibular

Moderate

Mild

718.87 Ankle instability

Gameday L1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

Initial Visit

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delayed healing Rebound L1906 L1951 National Ceiling Fee $139.98 $505 Velocity ES L1906 L1971 National $505 Ceiling Fee $139.98 Arizona Sporty L1940, L2330, L2820 National $742 Ceiling Fee $1133.81

Degenerative Joint Disease, Ankle, Rearfoot

Initial Visit Mild

715.17 Osteoarthritis, ankle, foot

Gameday L1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

719.47 Arthralgia, ankle, foot

Moderate Rebound with Stability Strap L1906 L1951 National$505 Ceiling Fee $139.98 Velocity ES L1906 L1971 National $505 Ceiling Fee

755.69 Tarsal coalition

$139.98

Subsequent Visit Severe Equalizer Air Walker L4360 National $312Ceiling Fee $322.31 Equalizer Premium Walker L4360 National $312Ceiling Fee $322.31 SP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312

Gameday LL1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

Arizona AFO Standard L1940, L2330, L2820 National $742Ceiling Fee $1133.81

XP Pneumatic Walker L4360 National $312Ceiling Fee $322.31

Pediatric Fracture 719.07 Effusion of joint, ankle, foot

824.2 Ankle fracture, lateral malleolus only

845.02 Sprain and strain of ankle and foot, calcaneofibular

824.6 Ankle fracture, trimalleolar

845.01 Sprain and strain of ankle and foot, deltoid ligament

Initial Visit SP Pneumatic Air Walker L4360 National $312Ceiling Fee $322.31

Subsequent Visit Air-Stirrup, pediatric size L4350 National $100 Ceiling Fee $104.06

SP Pneumatic Air Walker L4360 $312

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s) and charges. Price reflect the 2010 HCPCS national ceiling. Actual reimbursement may vary.

5

Tarsal Tunnel Syndrome 355.5 Tarsal tunnel syndrome 719.47 Pain in joint, ankle, foot

Initial Visit Mild Gameday L1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

Moderate Rebound with Stability Strap L1906 L1951 National Ceiling Fee $505 $139.98 Velocity ES L1906 L1971 National $505 Ceiling Fee $139.98

Sinus Tarsi Syndrome 726.79 Enthesopathy of ankle and tarsus 719.47 Pain in joint, ankle, foot

Severe Equalizer Air Walker L4360 National Ceiling Fee $322.31 $312 Equalizer Premium Walker L4360 National $312Ceiling Fee $322.31

Initial Visit Mild Gameday L1906 Revised L1902 National $135 Ceiling Fee Revised $92.19 $92.92

Moderate Rebound L1906 L1951 National $505Ceiling Fee $139.98

Velocity ES L1906 L1971 $505 National Ceiling Fee

Severe Equalizer Air Walker L4360 $312 National Ceiling Fee $322.31 Equalizer Premium Walker L4360 National Ceiling Fee $322.31 $312 SP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312 XP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s). Price reflect the 2009 DMEPOS national ceiling. Actual reimbursement may vary.

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XP Pneumatic Walker L4360 National$312 Ceiling Fee $322.31

Subsequent Visit

$139.98

6

SP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312

Gameday L1906 Revised L1902 National Ceiling Fee $135 Revised $92.19 $92.92

Flaccid Drop Foot 736.79 Acquired deformity of foot and ankle 438.20 Hemiplegia 719.97 Joint derangement, ankle and foot

Initial Visit

343.9 Infantile cerebral palsy 340 Multiple Sclerosis 138 Poliomyelitis, late effects

736.79 Acquired deformity of foot and ankle 438.20 Hemiplegia 719.97 Joint derangement, ankle and foot 728.85 Spasm of muscle

$933.98

For greater medial/lateral stability Dynamic National L1932 Ceiling Fee $992.39 $952

356.1 Peroneal muscle atrophy, Charcot Marie Tooth disease

Spastic Equinus

PeroSupport.tec L1951 National $905 Ceiling Fee

Initial Visit Arizona AFO Tall L1940, L2330, L2820 National $742 Ceiling Fee $1133.81

Arizona AFO Extended L1960, L2330, L2820 National $809 Ceiling Fee $1203.36

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s) and charges. Price reflect the 2010 HCPCS national ceiling. Actual reimbursement may vary.

7

Rigid Equinovarus

Post Sx

Initial Visit

754.51 Talipes equinovarus, congenital

Arizona AFO Tall L1940, L2330, L2820 National $742 Ceiling Fee $1133.81

736.71 Equinovarus, acquired

Arizona AFO Extended L1960, L2330, L2820 National Ceiling Fee $809

825.25 Fracture of the metatarsal bone

Initial Visit

733.94 Stress fracture, unspecified 825.25 Fracture of the metatarsal bone

Equalizer Premium Walker L4360 National Ceiling Fee $322.31 $312

®

®

Subsequent Visit Pro ready made orthotic L2999 Patient pays

Med-Surg Shoe L2999 Patient pays

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s). Price reflect the 2009 DMEPOS national ceiling. Actual reimbursement may vary.

8

Equalizer Premium Walker L4360 National $312Ceiling Fee $322.31

719.47 Pain joint, foot

$1203.36

Metatarsal Fracture

Initial Visit

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Med-Surg Shoe L2999 Patient pays

Charcot (Active)

Initial Visit

713.5 Arthoropathy associated with neurological disorder

Total Contact Cast, Non-weightbearing 24455, Q4038 $205

715.17 Osteoarthritis, localized foot and ankle

Charcot Conformer L4360 $312

Subsequent Visit If patient noncompliant and weight-bearing CROW L1960, L2340, L2820 Revised L4361 National $1228 Ceiling Fee Revised $1701.53 $1715.14

Charcot (Static) 715.17 Osteoarthritis, localized foot and ankle 734 Talipes planus

XP Pneumatic Walker L4360 National Ceiling Fee $322.31 $312

Initial Visit Custom molded shoes, offset heels, rocker bottom soles A5501 x 2, A5506 x 2, A5503 x 2 $519 Arizona AFO Standard L1940, L2330, L2820 National $742 Ceiling Fee $1133.81

Crutches E0114 National $49Ceiling Fee $51.10

Diagnoses are meant only as possible suggestions. The treating physician is the ultimate decider of the most appropriate diagnosis code(s) and charges. Price reflect the 2010 HCPCS national ceiling. Actual reimbursement may vary.

9

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PODIATRIC PRACTICE MANAGEMENT

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The codes contained herin are not the official position or endorsement of any organization or company. They are offered as a suggestion based upon input from previous customers. Each prescribing practioner should contact his or her local insurance carrier to verify billing codes, regulations, guidelines and fees relevent to their geographic location.