Introduction to Custom

DME

Patient Recognition

Casting

Dispensing

Documentation

Recognize Patients in

Need

Train Staff to be Aware Staff has many opportunities before the doctor “sees” the

patient to recognize a need for custom devices

Without diagnosing, staff can recognize:

A patient with instability (with or without an assistance device)

A patient who shuffles their feet

A patient with improper shoegear/support

A patient with ankle/foot deformity

A patient whose feet/ankles roll in (appear to hit the floor when walking

These Patients May

Benefit From a custom device such as:

A standard gauntlet style brace

An articulated brace

A low profile/sporty brace

A balance device(s)

A device that provides the patient with enough

control to reduce the progression of chronic

conditions as well as to reduce pain and improve

mobility and quality of life.

Patients Suffering with

Chronic Conditions Have 3 choices:

1. Do nothing and experience increased pain, decreased mobility, and an inability to maintain an active lifestyle

2. Have invasive surgery, which will require immobilization/delayed healing for an extended period of time

3. Be fitted for and wear a custom device that will slow the progression of their condition, reduce pain, and improve mobility and quality of life

The Presentation Following the recognition of patients who “qualify” for a

custom device, it is important to present the facts and

allow the patient to make an educated decision.

Give examples of patients with similar conditions who

have benefited from such devices.

Stay positive about the patient’s prognosis (if compliant).

Be confident in your approach.

Utilize staff to reiterate the benefits of custom devices.

Whenever Possible,

Follow the Rules

“Least expensive method of treatment first”

Utilize pre-fabricated devices to demonstrate (to the

patient and through documentation) the need for a

custom device.

Example: Patient with mild-moderate PT Tendon

Dysfunction or Chronic Ankle Sprains

Begin with and

document Begin by dispensing a Figure 8 brace – L1902, or a

pre-fabricated hinged brace with a rigid foot bed

(Suggestion: Comfortland Accord III) – L1971

Document to what degree the brace has helped

(according to the patient’s subjective description as

well as through objective findings such as decreased

swelling and irritation).

Also document the need for a more substantial

device for long term use (as the condition is chronic).

The Next Step: Custom

Once the need for a custom device(s) has been

established, the next step is to cast your patient and

document the following:

Diagnosis(es)

Medical Necessity

Therapeutic Objectives

Device most appropriate to achieve Therapeutic Objectives

Balance Braces Patients with notable balance issues including

muscle weakness and instability:

When calling a patient back from the reception area,

walking alongside and then behind the patient as the

patient is instructed toward the treatment room, staff

can easily observe signs of:

• Difficulty in “get up and go,” jerking motions when

turning or entering a treatment room, shuffling

feet, and use of assistance device – i.e. cane,

walker

Once Identified The staff member completes a Fall Risk Assessment (FRA)

MA scores the assessment (adds up individual areas) and

categorizes the patient into the appropriate fall risk category

(clearly listed on the bottom of the form)

MA leaves the completed FRA for the DPM to review with

the patient during treatment, allowing the following

recommendations to be made (depending on severity of fall

risk):

Custom braces (Moore Balance Brace B/L – for fall prevention)

Physical Therapy Program

A combination of both

Diagnoses are Made All/most possible Dx codes are listed in the MBB

compliance packet – provided by Safestep/Arizona AFO

Examples:

Muscle weakness (728.87)

Ataxia, muscular incoordination (781.3)

Gait abnormality/staggering, ataxic (781.2)

Osteoarthritis, localized primary ankle and foot (715.17)

Arthropathy, unspecified, ankle and foot (716.97)

Pain in joint, ankle, foot (719.47)

Instability of joint, ankle, and foot (718.87)

Dropfoot (736.79)

Hemiplegia (438.20)

Therapeutic Objectives For the DPM, as the Prescriber and Supplier of Custom Devices,

many of the same guidelines need to be followed (as with dispensing other types of DME).

The Differences:

Therapeutic shoes/inserts require the patient’s Primary Care Physician to agree with the DPM’s findings and state that they manage the patient’s Diabetes before shoes can be dispensed.

Pre-fabricated and Custom braces and devices do not require PCP sign- off prior to dispensing

The DPM determines medical necessity and therapeutic objectives (essentially writing the Rx) and then is able to dispense the device – Prescriber and Supplier

Fit the Needs of your

Patients

Many patients with chronic ankle deformities and

commonly-seen conditions may be ideal candidates

for custom AFOs:

PT tendon dysfunction

Past trauma

Frequent sprains or strains

Incidences such as stroke, etc.

More Possible

Diagnoses

Adult acquired flatfoot - 734

Congenital flatfoot – 754.61

Pronation, acquired – 736.79

Joint pain; ankle & foot – 719.47

Tarsal coalition – 755.67

Dropfoot – 736.79

Calcaneofibular ligament sprain –

845.02

Charco ̂t’s arthropathy – 713.5

Tendon rupture; ankle & foot –

727.68

Chronic tibialis posterior tendonitis –

726.72

Instability of joint; ankle & foot –

718.87

Osteoarthrosis; ankle & foot – 715.17

Traumatic arthropathy; ankle & foot –

716.17

Deltoid ligament sprain – 845.01

Chronic Achilles tendonitis

Many Devices to

Choose From Arizona brace – standard (most common)

Sporty (lowest profile)

Articulated (hinged)

Unilateral Balance brace (works extremely well for

flaccid drop foot)

Customize Further Patients have a choice of color and closure

Black or tan leather is popular

Arizona braces are also available in the breeze

material (same as balance brace)

Whenever possible, encourage lace closure

(regular or speed laces)

Velcro is easy but makes the brace much more

bulky and difficult to fit into most shoes

No Need to Memorize

If uncertain of which type of brace to prescribe:

Cast the patient

Take a picture of the patient’s foot (feet)/ankle(s)

Send the picture to Arizona (brace company) and ask

for suggestions

If the cast is good (accurate depiction of the patient’s

foot/ankle in a “neutral” position, a brace style can be

determined post-casting (ask color and closure

preference of the patient before they leave the office).

Sample Objectives:

To improve stability and gait and . . .

To reduce fall risk through the incorporation of a

physical therapy strengthening program, in addition to

dispensing of custom braces to control the foot and

ankle and improve proprioception

Patient is Ready to be

Casted Compliance paperwork should accompany patient

to casting for clarification (if dx, therapeutic

objectives, or brace recommendation is not filled in,

the patient should not be casted).

Document FRA score and category (example: severe

fall risk) in patient’s electronic chart note along with

mention of “casting to be performed today, patient to

return in 2-3 weeks for dispensing of braces.”

If physical therapy is recommended, this should also be

clearly documented.

Preparation 2 pairs of gloves

Black plastic piece

Plastic tube

Plastic bag to cover leg

Paper tape

Basin for water/close to sink

Small curved scissors

STS casting socks

Step stool/solid casting wedge

Positioning It is most important to

capture the patient at as much of a 90 degree ankle as possible.

A good cast will serve as the “negative” of which the brace will be fabricated.

Bad brace, bad cast

Casting – Step 1.

Step 2.

Step 3.

Step 4.

Step 5.

Step 6.

Step 7.

Coding may Vary

Most often (for standard and sporty Arizona braces), the codes are the same as the balance brace – but are more commonly unilateral

L1940, L2820, L2330 (for Balance Braces, these are bilateral)

Hinged or Articulated

Styles (Devices that meet the description as L1970),

“AFO, plastic with ankle joint, custom fabricated” are

no longer required extend to within 4 cm of the fibular

head. When they include a soft interface, code L2820

can also be billed.

Less Common AFOs Other custom braces such as the CROW walker

(used commonly for stabilizing the foot during

active charcot changes): Bill one code only:

L4631

These braces come up to the fibular head

and require casting with a Bermuda

(extended to the knee) STS sock

Dispensing Setting realistic expectations for your patients is key.

Advise your patients to bring more than one pair of shoes with them when they pick up their brace(s).

It may be necessary to fit the patient with a pair of extra depth shoes in order to accommodate their brace.

The importance of a slow break-in period must be relayed to the patient (similarly to a custom orthotic).

Adjustments can be made if necessary but are often avoidable with proper instruction.

Paperwork Patients must sign and date a receipt when picking

up their brace(s).

A copy is made, one given to the patient and one

kept in the electronic chart

30 Supplier Standards (Form) must also be given to

patient during dispensing

Medicare Billing must only take place once the

devices have been dispensed

Questions?

Please contact a member of our Team at

Pinnacle Practice Achievement, LLC

info@pinnaclepa.com