How To Maximize Patient Outcomes With DME

Author(s): 
By William N. McCann, DPM

      The use of durable medical equipment (DME) has grown to become a part of almost every podiatric practice over the last half-century. In fact, podiatrists have led the field in this important area of patient treatment through our use of orthotic devices.       With our extensive background and training in biomechanics, our understanding of diabetes and its complications in the lower extremities as well as a need to provide patients with immediate immobilization, it is no wonder that DME is one of the more important offerings that we can extend to those we treat. Durable medical equipment is a critical piece of many treatment protocols due to its ease of use, patient acceptance and ability to maximize outcomes. Practically speaking, integrating DME into existing treatment protocols will improve and diversify your practice revenue stream.       Durable medical equipment is defined as items of medical equipment owned or rented that are placed in the home to facilitate treatment and/or rehabilitation. DME generally consists of items that can withstand repeated use. These items are primarily and customarily used to serve a medical purpose, and are usually not useful to a person in the absence of illness or injury. Durable medical equipment items can be custom or non-custom.       Most surveys show that podiatrists nationwide are now participating in therapeutic shoe and insole dispensing for their patients with diabetes. However, fewer DPMs are dispensing items regularly to their patients for sprains, fractures, tendonitis, unstable foot and ankle deformities, postoperatively or for offloading wounds. To maximize your patients’ outcomes, you will need to consider adding some or all of these items to your DME program. As a prescribing practitioner, you should contact your local insurance carriers, Medicare or Medicaid to verify billing codes, regulations, guidelines and fees relevant to your geographic area.

Understanding The Basics Of Common DME Coding

      Here is a list of DME common to podiatric medicine and their respective codes:       • Gauntlet-style ankle braces, prefabricated (L1902)       • Multiligamentous ankle support, prefabricated (L1906)       • Pneumatic ankle braces (L4350)       • Non-pneumatic walking boots (L4386)       • Pneumatic walking boots (L4360)       • Plantar fascia night splints (for plantar fasciitis or plantarflexion contracture of ankle joint) (L4396)       • Added depth shoes (A5500)       • Heat molded, non-custom orthotics (A5512)       • Custom orthotics (L3000-L3030)       • Custom amputation filler orthotic (L5000)       • Custom articulated hinge AFO (L1970, L2820)       • Custom solid AFO (L1960)       • Custom Gauntlet AFO (L1940, L2820, L2275, L2280)       • Collagen wound dressing (A6021)       • Foam dressing, wound cover (A6212)       • Gauze-impregnated hydrogel for direct wound contact (A6231-A6233, A6242-A6248)       Most insurers reimburse DME. Medicare, which handles these devices through one of four Durable Medical Equipment Regional Carriers (DMERC), requires a separate provider number in order to submit claims. While compliance is a critical element of participation in DMERC, the specifics of dispensing any of these items to a compliant patient cannot be completely covered within the scope of this article. However, there are Internet resources available to educate you and your staff on current Medicare regulations as they apply to the DME you dispense. Here are some resources to consider:       • www.medicarenhic.com (Region A)       • www.adminstar.com (Region B)       • www.palmettogba.com (National Supplier Clearing House and Region C)       • www.noridianmedicare.com (Region D)

How To Navigate The Criteria Of Medical Necessity For DME

      DME has a place for many of the conditions we treat on a daily basis in our offices. Unlike evaluation and management services or procedures that are diagnosis driven, DME must simply meet medical necessity. For an item to be considered for coverage under the brace benefit category, it must be a rigid or semi-rigid device that one utilizes to support a weak or deformed body part, or for restricting or eliminating motion in a diseased or injured body part. It must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is bracing.       The exceptions to the rule of meeting medical necessity are the use of walking boots, both pneumatic and non-pneumatic (L4360 and L4386) for ulcers as well as the use of a static AFO (L4396) for the diagnosis of plantar fasciitis (728.71) or a plantarflexion contracture of the ankle (718.47). Use of a static AFO (night splint) for a plantarflexion contracture of the ankle requires meeting four criteria while the diagnosis of plantar fasciitis alone will justify using this AFO.       For example, the code is L4396 for a static AFO (night splint). To obtain coverage, one must meet the first four conditions or the fifth condition listed below.       • Plantarflexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture); and       • reasonable expectation of the ability to correct the contracture; and       • contracture is interfering or is expected to interfere significantly with the patient’s functional abilities; and       • is used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.       • The patient has plantar fasciitis (ICD-9 diagnosis code 728.71).       If one uses a static AFO for the treatment of a plantarflexion contracture, the clinician must measure the pre-treatment passive range of motion with a goniometer and document it in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or a caregiver (at home).

Pertinent Pointers On Using AFOs To Treat Plantar Fasciitis

      Plantar fasciitis is one of the most commonly treated problems in podiatric practice. Treatment protocols may vary among podiatric physicians but one must give consideration to the use of appropriate DME to treat this condition. In addition to orthotics, two important prefabricated AFOs can enhance patient outcomes. These are night splints (L4396) and pneumatic (L4360) or non-pneumatic (L4386) walking boots for short-term immobilization.       While neither of these AFOs is necessarily a first-line treatment, one must consider them as important adjuncts to standard therapy for plantar fasciitis. For example, a patient may present with continued heel pain following a single corticosteroid injection and a regimen of stretching, ice, NSAIDs and use of a pair of prefabricated orthotics. You may decide to cast the patient for a pair of functional orthotics, apply a plantar rest strap, change the NSAID and dispense a night splint.       Later in the treatment protocol, facilitating a short course of immobilization via a pneumatic or non-pneumatic walking boot can relieve symptoms. In regard to the rationale for choosing a pneumatic walking boot, the clinician should base this on the edema of the extremity and the extent to which the device will demonstrably control the edema. If a pneumatic device will not have a direct impact on the edema, then selecting a non-pneumatic walking boot is more appropriate.

What About Using DME To Treat Ankle Sprains?

      Most busy podiatry offices frequently encounter ankle sprains. Multiple prefabricated AFOs are indicated for proper treatment and DPMs use them as first-line treatment along with other supportive measures. The choice of AFO will be based on the degree of severity of the injury. The key is to facilitate proper diagnosis, treatment and, ultimately, prevention of prevent future injury in the most efficient and cost-effective manner. Patients, especially athletes, need to rehab the ankle as quickly as possible and be able to return to the game with confidence that they will not reinjure the ankle complex.       For example, a severe ankle sprain may require multiple layer compression with posterior splint and non-weightbearing with crutches initially. This may be followed by a period of weightbearing in a pneumatic walking boot. The patient can then graduate into a pneumatic stirrup (L4350) if edema control and stability are needed. Patients can wear a gauntlet-style ankle brace (L1902) if stability during activity without edema control is the goal. The use of these prefabricated devices is always in conjunction with logical rehabilitation measures such as physical therapy, rest, ice, elevation and NSAIDs.

What You Should Know About Custom DME

      Custom fabricated DME has become a rapidly growing segment of the treatment options available for our patients. Custom-fabricated AFOs are covered for ambulatory patients when the medical necessity criteria is satisfied and one of the following criteria are met.       • The patient could not be fit with a prefabricated AFO.       • The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six months).       • There is a need to control the knee, ankle or foot in more than one plane.       • The patient has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury.       • The patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.       The most common custom DME used by podiatrists include articulated hinge devices, gauntlet style devices and solid ankle foot orthoses (SAFO). Articulated hinge AFOs (L1970, L2820) allow sagittal plane motion at the ankle while restricting motion in the transverse and frontal plane. These are ideal for moderate PTTD, lateral ankle instability and rearfoot and ankle osteoarthritis where non-custom devices have failed. This is an excellent device for both pediatric and adult treatment in a sports medicine setting. One may modify articulated hinge AFOs with optional dorsiflex assist additions medially and/or laterally (L2210, bill with x2 modifier when used medially and laterally). Clinicians may also build varus/valgus correction into the device (L2275).       Gauntlet style AFOs (L1940, L2820, L2275, L2280) allow little or no motion in all three planes. These have a leather exterior with lace-up and/or Velcro closures, and a fitted polypropylene posterior component. Patients who have difficulty bending over or who have arthritis of the hands may benefit from Velcro closures. There are a variety of heights available and selection here is based on the severity of the condition one is treating. For example, painful medial column osteoarthritis may require a short or standard length gauntlet AFO, whereas Charcot changes of the midfoot may require a taller version of the device or consideration of a solid ankle foot orthosis. Other indications include ankle osteoarthritis, severe PTTD, traumatic osteoarthritis and triplanar deformity.       Patients with diabetes are one of the largest growing segments of podiatric practice today. Podiatrists have long been viewed as critical specialists in diagnosing and treating this patient population. A wide variety of custom and non-custom AFOs as well as wound care products are well suited for patients with diabetes demonstrating lower extremity risk factors.

What About Orthoses For Those Who Have Had Amputations?

      Many podiatrists work under the assumption that orthotic devices are a non-covered service. However, Medicare, through DMERC, will pay for functional full-length orthotics, with an amputation filler for patients who have had their foot or any part of their foot amputated. The reason for the amputation can be due to diabetes, PVD, infection or trauma. The prescribing physician should document the reason why the amputation filler is a medical necessity. For example, a patient with a hallux amputation may require a filler to stabilize propulsion and prevent excessive motion of the foot within the shoe, thus preventing ulceration or other limb-threatening injuries.       Another example is a patient who has had a second toe amputation and demonstrates hallux valgus or a significant risk of hallux abductus following the operation. When billing, use the code L5000 with a right and/or left modifier. In addition to the patient’s other diagnoses, you must also use the appropriate ICDM-9-CM V Code signifying the patient’s amputation status.       V codes are a supplementary classification of factors influencing health status and contact with health services. Your ICDM-9-CM code book often provides little or no direction on the use of these codes. In this instance, you must use V49.71, V49.72 or V49.73 to properly signify your patient’s pedal amputation status. Diabetes is not a coverage prerequisite. If the patient does have diabetes, you can dispense the device with a pair of added depth shoes (i.e., Medicare program) as well as heat molded or custom insert(s) for the limb without amputation. All of these are reimbursable.       The following are V codes for the amputation status of the foot:       • V49.71 – Amputation of hallux       • V49.72 – Amputation of other toes       • V49.73 – Amputation of foot

In Conclusion

      Durable medical equipment plays a critical role in the treatment of an ever expanding list of conditions frequently seen by podiatric physicians. Patients often immediately need these products and they should be available for dispensing in the office. While coding, billing and reimbursement as well as compliance with regulations for dispensing these items are available from federal and private health insurance carriers, the information is dynamic. Frequent review of local carrier policies and Medicare DMERC local carrier determinations will be necessary to ensure compliance as a DME supplier.       As specialty providers of comprehensive foot and ankle care, DPMs are well positioned to improve patient outcomes and patient satisfaction significantly with the proper use of DME.       Dr. McCann is a Diplomate of the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He is the President and Fellow of the American Academy of Podiatric Practice Management (www.aappm.org/). He is also a New Hampshire Podiatry Political Action Committee coordinator. Dr. McCann is in private practice in Concord, N.H.

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