SECTION D: AFO SERIES OF CODES - c.ymcdn.comc.ymcdn.com/.../resmgr/infodmepossupp/pcm_4_section_d-afoseriesofc.pdfSECTION D: AFO SERIES OF CODES. ... have begun to learn how to make,

Modern Coding for Foot and Ankle DMEPOS HCPCS Codes Page - 193

SECTION D: AFO SERIES OF CODES

Page - 194 Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

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CHAPTER DA: INTRODUCTION TO ANKLE FOOT ORTHOSES

OverviewUntil the last two decades, very few pedorthists used more than a few of the codes in this section because themajority of these codes have historically been considered outside the pedorthist’s scope of practice. These codeshave traditionally been used by orthotists, prosthetists, podiatrists, and physical therapists.

With the advent of the Subtalar Control Foot Orthosis (SCFO), which is clearly within the Pedorthic scope of practice,and with the increasing tendency for pedorthists to practice in Orthotic & Prosthetic companies, many pedorthistshave begun to learn how to make, fit, and dispense AFOs and AFO codes. If their certification and/or licensure asa pedorthists does not include these devices, then the pedorthist must become a certificant from another body (i.e.a manufacturer of the devices) and dispense those items as a certificant of that other body, not as a certified and/orlicensed pedorthist. The O&P licensure laws in some states may restrict a non-cross credentialed pedorthist fromperforming this work. The PCC suggests that all pedorthists stay abreast of the licensure laws in their state.

Even if a device falls within a practitioner’s scope of practice or licensure, it should only be performed by thatpractitioner if it is also within the practitioner’s scope of competence. The PCC suggest all pedorthists seek outcontinuing education on SCFOs and AFOs and to utilize their full scope of practice and/or licensure. Credentialingbodies define scopes of practice descriptively, not proscriptively. If a majority of practitioners within a field learn anew skill and begin to incorporate that into their practice, that new skill will eventually be officially added to the scopeof practice.

SCFOA Subtalar-Control Foot Orthosis (SCFO) has been defined as a lower extremity orthosis designed to manage thefunction of the anatomy distal to the ankle joint* by controlling the range of motion of the subtalar joint**. The proximallength of a SCFO does not extend beyond the musculotendonis junction of the gastrocnemius and the calcaneal(Achilles) tendon. A SCFO is a method of treatment of conditions related to the foot demanding additional surfacearea to control forces. A SCFO does not include a supramalleoli orthosis. SCFOs are billed using AFO HCPCScodes. The following definitions apply:

*Ankle JointAnkle Joint Articulations

· Taluso Talar trochlea

· Tibiao Inferior articular surfaceo Articular surface of the medial malleolus

· Fibulao Articular surface of the inferior lateral malleolus

Ankle Joint Function: The ankle joint is a single plane joint consisting of the sagital motionsof plantar flexion and dorsiflexion

**Subtalar JointSubtalar Joint Articulations

· Calcaneouso Middle articular surfaceo Posterior articular surface

· Taluso Talo-calcaneal


o Talo-navicularSubtalar Joint Function: The subtalar joint is a multi-plane or tri-plane motion joint consistingof the frontal plane motion of inversion/eversion, the transverse plane motion of abduction/adduction, and the sagital plane motion of flexion/extension.

L4360, L4386, L4396, and L4398 AND THE TREATMENT OF ULCERSThe LCD for AFOs specifically prohibits the use of these devices solely for the treatment of ulcers, but does providesome coverage for certain orthopedic deformities. However, for a neuropathic patient, the orthopedic deformitiesand ulceration generally go hand in hand. The LCD indicates that at least part of the reason for non-coverage is thatthe TSD benefit can handle the need. However, many of these devices would clinically be helpful to get ulcersreduced, and then the TSD devices are used to finish the closing and prevent further ulceration. The PCC encouragesCMS to revisit this issue because the PCC believes that it is in the patient’s best interest, and society’s best interest,to have a large and varied armamentarium of tools to combat ulcers—given their potentially dramatic outcomes andtheir potentially staggering cost to society. Coverage issues often affect a doctor’s decision on treatment (and thepatient’s ability to pay for a device) and the lack of coverage on something this important limits the patient’s healthcare provider and puts the patient at additional risk.

L2275This code is used for INCREMENTAL work done to either 1) intrinsically to the positive model of an AFO cast priorto plastic forming, or 2) extrinsically to a finished AFO, in order to provide ADDITIONAL varus/valgus corrective forceover what would be available from a cast taken in neutral, semi-weightbearing position. To be billed to insurance,this incremental correction must be specifically prescribed by the prescriber and the practitioner and fabricating labmust have documentation or other evidence of actual completion of the incremental work (or this incrementalcorrection must be noticeable in the finished device). Since this is an incremental step, it should would not beappropriate for payors to ignore paying for it. In late 2008, PDAC made some announcements regarding the use ofthis code for certain types of AFOs. The PCC does not agree with PDAC’s findings, but PDAC has the authority toenforce such findings and all suppliers must follow PDAC’s findings until such time as they are amended.

Other Definitions:

The PCC has developed the following clarifying definitions, as they relate to AFOs.

Solid ankle AFO: an AFO that does not bend or articulate at the ankle joint. It is used when total immobilization ofthe ankle joint is required.

Limited ankle AFO: an AFO that allows limited motion or articulation at the ankle joint, commonly limiting plantarflexion to 90 degrees.

Articulated AFO: the AFO can bend freely at a hinge. This usually involves two hinges, one near each malleolous.These hinges connect the upper portion of the AFO to the foot portion of the AFO.

Dorsiflexion assist (aka dorsi-assist) AFO: this is an AFO whose design will encourage dorsiflexion of the ankle attoe-off. These devices store energy after heel strike and release the energy at toe-off.

Fracture orthosis: an orthosis whose design completely encompasses the affected body part in rigid plastic so asto immobilize the affected body part and promote healing. Total encompassing is usually achieved by a bi-valvedesign.


Stirrup: That part of the AFO/plate that 1) is permanently attached to the shoe, and 2) is also attached and connectedto the upper leg portion of the AFO.

Upright: That part of the AFO that encompasses 1) the ankle and 2) includes the section below the knee.


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CHAPTER DB: OFFICIAL MEDICARE LCD AND POLICY ARTICLE FOR ANKLE-FOOT/KNEE-ANKLE-FOOTORTHOSIS (L11517) FOR EFFECTIVE DATE OF JANUARY 2011.

Indications and Limitations of Coverage and/or Medical NecessityFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) bereasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of amalformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For theitems addressed in this local coverage determination, the criteria for “reasonable and necessary”, based on SocialSecurity Act §1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/ormedical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier beforea claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completedorder, the item will be denied as not reasonable and necessary.

AFOs NOT USED DURING AMBULATION:

An L4396 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met:

1. Plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsiflexion on passive range ofmotion testing of at least 10 degrees (i.e., a nonfixed contracture); and2. Reasonable expectation of the ability to correct the contracture; and3. Contracture is interfering or expected to interfere significantly with the patient’s functional abilities; and4. Used as a component of a therapy program which includes active stretching of the involved muscles and/ortendons.5. The patient has plantar fasciitis (ICD-9 diagnosis code 728.71)

If an L4396 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion mustbe measured with a goniometer and documented in the medical record. There must be documentation of anappropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

An L4396 and replacement interface (L4392) will be denied as not reasonable and necessary if the contracture isfixed. Codes L4396 and L4392 will be denied as not reasonable and necessary for a patient with a foot drop butwithout an ankle flexion contracture. A component of a static/dynamic AFO that is used to address positioning of theknee or hip will be denied as not reasonable and necessary because the effectiveness of this type of componentis not established.

If code L4396 is covered, a replacement interface (L4392) is covered as long as the patient continues to meetindications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum ofone (1) per 6 months. Additional interfaces will be denied as not reasonable and necessary.

Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface(L4394). A foot drop splint/recumbent positioning device and replacement interface will be denied as not reasonableand necessary in a patient with foot drop who is nonambulatory because there are other more appropriate treatmentmodalities.

AFOs AND KAFOs USED DURING AMBULATION:

Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization formedical reasons, and have the potential to benefit functionally.


Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered forambulatory patients for whom an ankle-foot orthosis is covered and for whom 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 reasonable andnecessary.

AFOs and KAFOs that are custom-fabricated are covered for ambulatory patients when the basic coverage criterialisted above and one of the following criteria are met:

1. The patient could not be fit with a prefabricated AFO, or2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6months), or3. There is a need to control the knee, ankle or foot in more than one plane, or4. The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating overa model to prevent tissue injury, or5. The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for acustom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and necessary.

L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not reasonableand necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonableand necessary.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are anintegral part of a brace.

MISCELLANEOUS:

Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the patient’scondition, or irreparable accidental damage is covered if the device is still reasonable and necessary. The reasonfor the replacement must be documented in the supplier’s record.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether theoriginal item is worn out, are denied as not reasonable and necessary.

Quantities of supplies greater than those described in the policy as the usual maximum amounts, in the absence ofdocumentation clearly explaining the medical necessity of the excess quantities, will be denied as not reasonableand necessary.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report thisservice. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Completeabsence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should beassumed to apply equally to all claims.


Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used toreport this service. In most instances Revenue Codes are purely advisory; unless specified in the policyservices reported under other Revenue Codes are equally subject to this coverage determination. Completeabsence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policyshould be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY - No physician or other licensed health care provider order for this item or service.GA – Waiver of liability statement issued as required by payer policy, individual caseGZ – Item or service expected to be denied as not reasonable and necessaryKX - Requirements specified in the medical policy have been metLT - Left SideRT - Right Side

HCPCS CODES:

A4466 GARMENT, BELT, SLEEVE OR OTHER COVERING, ELASTIC OR SIMILAR STRETCHABLE MATERIAL, ANY TYPE, EACHA9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACHL1900 ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOMFABRICATEDL1902 ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL1904 ANKLE FOOT ORTHOSIS, MOLDED ANKLE GAUNTLET, CUSTOM-FABRICATEDL1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTL1907 AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATEDL1910 ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL1920 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEINTYPE), CUSTOM-FABRICATEDL1930 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL1932 AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTL1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATEDL1945 ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION),CUSTOMFABRICATEDL1950 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATEDL1951 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHERMATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATEDL1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATEDL1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT


L1980 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR ‘BK’ ORTHOSIS), CUSTOMFABRICATEDL1990 ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALFBAND/CUFF (DOUBLE BAR ‘BK’ ORTHOSIS), CUSTOM-FABRICATEDL2000 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGHAND CALF BANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATEDL2005 KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL,AUTOMATIC LOCK AND SWING PHASE RELEASE, MECHANICAL ACTIVATION, INCLUDES ANKLE JOINT, ANYTYPE, CUSTOM FABRICATEDL2010 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALFBANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATEDL2020 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALFBANDS/CUFFS (DOUBLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATEDL2030 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALFBANDS/CUFFS, (DOUBLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATEDL2034 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTIONKNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDL2035 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL2036 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTIONKNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDL2037 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTIONKNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDL2038 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE, MULTIAXISANKLE, CUSTOM FABRICATEDL2106 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTICTYPE CASTING MATERIAL, CUSTOM-FABRICATEDL2108 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOMFABRICATEDL2112 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTL2114 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL2116 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTL2126 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS,THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATEDL2128 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATEDL2132 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTL2134 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTL2136 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTL2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE JOINTSL2182 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINTL2184 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINTL2186 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DJUSTABLE MOTION KNEE JOINT, LERMAN TYPE


L2188 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIML2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELTL2192 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH FLANGE,AND PELVIC BELTL2200 ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINTL2210 ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINTL2220 ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINTL2230 ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENTL2232 ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOTORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLYL2240 ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENTL2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENTL2260 ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)L2265 ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUPL2270 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION (‘T’) STRAP, PADDED/LINED OR MALLEOLUS PADL2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINEDL2280 ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOTL2300 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLEL2310 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHTL2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYL2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATEDORTHOSIS ONLYL2335 ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BANDL2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODELL2350 ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL,(USED FOR ‘PTB’ ‘AFO’ ORTHOSES)L2360 ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANKL2370 ADDITION TO LOWER EXTREMITY, PATTEN BOTTOML2375 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUPL2380 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINTL2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINTL2387 ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLEFOOT ORTHOSIS, EACH JOINTL2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINTL2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINTL2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVEL2405 ADDITION TO KNEE JOINT, DROP LOCK, EACHL2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANYMATERIAL, EACH JOINTL2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINTL2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINTL2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RINGL2500 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RINGL2510 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODELL2520 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTEDL2525 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIMMOLDED TO PATIENT MODEL


L2526 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM,CUSTOM FITTEDL2530 ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDEDL2540 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODELL2550 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFFL2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BARL2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRIDLAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLYL2760 ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR LINEALADJUSTMENT FOR GROWTH)L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BARL2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NONCORROSIVE FINISH, PER BARL2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACHL2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAPL2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL,FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLYL2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PADL2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTIONL2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTIONL2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACHL2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACHL2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIEDL4002 REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPEL4010 REPLACE TRILATERAL SOCKET BRIML4020 REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODELL4030 REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTEDL4040 REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYL4045 REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYL4050 REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYL4055 REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYL4060 REPLACE HIGH ROLL CUFFL4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFOL4080 REPLACE METAL BANDS KAFO, PROXIMAL THIGHL4090 REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGHL4100 REPLACE LEATHER CUFF KAFO, PROXIMAL THIGHL4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGHL4130 REPLACE PRETIBIAL SHELLL4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTESL4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTSL4350 ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G.,PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL4360 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACEMATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL4386 WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTL4392 REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO


L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINTL4396 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLEFOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTL4398 FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTL4631 ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM,ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL,INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED

ICD-9 Codes that Support Medical Necessity

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the sectionon “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and paymentinformation.

For HCPCS codes L4392 and L4396:

718.47 CONTRACTURE OF ANKLE AND FOOT JOINT728.71 PLANTAR FASCIAL FIBROMATOSIS

For HCPCS code L4631:

713.5 ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS

Diagnoses that Support Medical Necessity

For the specific HCPCS codes indicated above, refer to previous section. For all other HCPCS codes, diagnosesare not specified.

ICD-9 Codes that DO NOT Support Medical Necessity

For the specific HCPCS code indicated above, all ICD-9 codes that are not specified in the preceding section. Forall other HCPCS codes, diagnoses are not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

For the specific HCPCS code indicated above, all diagnoses that are not specified in the preceding section. For allother HCPCS codes, diagnoses are not specified.

General Information

Documentation Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has beenfurnished such information as may be necessary in order to determine the amounts due such provider”. It is expectedthat the patient’s medical records will reflect the need for the care provided. The patient’s medical records includethe physician’s office records, hospital records, nursing home records, home health agency records, records fromother healthcare professionals and test reports. This documentation must be available upon request.


An order for each new or full replacement item must be signed and dated by the treating physician, kept on file bythe supplier, and made available upon request. Items billed before a signed and dated order has been received bythe supplier must be submitted with an EY modifier added to each affected HCPCS code.

The order must list the unique features of the base code that is billed plus every addition that will be billed on aseparate claim line. The medical record must contain information which supports the medical necessity of the itemand all additions that are ordered. An order is not necessary for the repair of an orthosis.

The supplier must include on the claim the ICD-9 diagnosis code for the underlying condition for a static or dynamicpositioning AFO (L4396) or replacement interface material (L4392).

For custom-fabricated orthoses, there must be documentation in the supplier’s records to support the medicalnecessity of that type device rather than a prefabricated orthosis. This information must be available upon request.

KX, GA, and GZ MODIFIERS:

Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the“Indications and Limitations of Coverage and or Medical Necessity” section of this policy have been met andevidence of such is retained in the supplier’s files and available to the DME MAC upon request.

If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not beenmet, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial,suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance BeneficiaryNotice (ABN) or the GZ modifier if they have not obtained a valid ABN.

Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.

MISCELLANEOUS

A claim for code L2999 must include either a narrative description of the item (for custom fabricated items) or themanufacturer name and model name/number (for pre-fabricated items). For replacement components billed withcode L2999, there must also be a HCPCS code or the manufacturer name and model name/number of the baseorthosis. This information should be entered in the narrative field of an electronic claim.

A claim for code L4205 must include an explanation of what is being repaired. A claim for code L4210 must includea description of each item that is billed. This information should be entered in the narrative field of an electronicclaim.

All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the sameclaim.

When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts,there must be documentation in the patient’s medical record supporting the medical necessity for the higher utilization.This information must be available upon request.

Refer to the Orthopedic Footwear policy for information on documentation requirements for shoes and related itemswhich are an integral part of a brace.

Refer to the Supplier Manual for more information on documentation requirements.


Policy Article

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) bereasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of amalformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Informationprovided in this policy article relates to determinations other than those based on Social SecurityAct §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

For an item to be considered for coverage under the Braces benefit category, it must be a rigid or semi-rigid devicewhich is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motionin a diseased or injured part of the body. It must provide support and counterforce (i.e., a force in a defined directionof a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used tobrace. Items that do not meet the definition of a brace are noncovered.

A static/dynamic Ankle-Foot Orthosis (AFO) (L4396) and replacement interface (L4392) are denied as noncovered(no Medicare benefit) when they are used solely for the prevention or treatment of a heel pressure ulcer because forthese indications they are not used to support a weak or deformed body member or to restrict or eliminate motionin a diseased or injured part of the body (i.e., it does not meet the definition of a brace). For reasonable andnecessary determinations for the use of L4396 and L4392 refer to the Medical Necessity Coverage and PaymentRules under “AFOs Not Used During Ambulation” in the AFO/KAFO Local Coverage Determination.

A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) are denied as noncovered(no Medicare benefit) when they are used solely for the prevention or treatment of a pressure ulcer because forthese indications they are not used to support a weak or deformed body member or to restrict or eliminate motionin a diseased or injured part of the body (i.e., it does not meet the definition of a brace). Forreasonable and necessary determinations for the use of L4398 and L4394 refer to the Medical Necessity Coverageand Payment Rules under “AFOs Not Used During Ambulation” in the AFO/KAFO Local Coverage Determination.

A foot pressure off-loading/supportive device (A9283) is denied as noncovered (no Medicare benefit), because itdoes not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part ofthe body.

Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigiddevices. Devices that are not rigid or semi-rigid must be coded A4466. Code A4466 is denied as noncovered (noMedicare benefit).

Socks (L2840, L2850) used in conjunction with orthoses are denied as noncovered (no Medicare benefit).

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether theoriginal item is worn out, are not covered.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are anintegral part of a brace.


CODING GUIDELINESAnkle flexion contracture is a condition in which there is shortening of the muscles and/or tendons that plantarflex theankle with the resulting inability to bring the ankle to 0 degrees by passive range of motion. (0 degrees ankleposition is when the foot is perpendicular to the lower leg.)

Foot drop is a condition in which there is weakness and/or lack of use of the muscles that dorsiflex the ankle butthere is the ability to bring the ankle to 0 degrees by passive range of motion.

Plantar fasciitis is an inflammation of the heel of the foot typically resulting from trauma to the deep tissue of the foot(i.e., plantar fascia).

A prefabricated orthosis is one which is manufactured in quantity without a specific patient in mind. A prefabricatedorthosis may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient(i.e., custom fitted). An orthosis that is assembled from prefabricated components is considered prefabricated. Anyorthosis that does not meet the definition of a custom-fabricated orthosis is consideredprefabricated.

A custom-fabricated orthosis is one which is individually made for a specific patient starting with basic materialsincluding, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantialwork such as cutting, bending, molding, sewing, etc. It may involve the incorporation of some prefabricatedcomponents. It involves more than trimming, bending, or making other modifications to asubstantially prefabricated item.

Ankle-foot orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around thelower leg above the ankle. These features distinguish them from foot orthotics which are shoe inserts that do notextend above the ankle.

A nonambulatory ankle-foot orthosis may be either an ankle contracture splint, night splint or a foot drop splint.

A static or dynamic positioning ankle-foot orthosis (L4396) is a prefabricated ankle-foot orthosis which has all of thefollowing characteristics:

1. Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45°; and2. Applies a dorsiflexion force to the ankle; and3. Used by a patient who is minimally ambulatory, or nonambulatory; and4. Has a soft interface.

A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of thefollowing characteristics:

1. Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and2. Not designed to accommodate an ankle with a plantar flexion contracture; and3. Used by a patient who is nonambulatory; and4. Has a soft interface.

Code L4631 describes a Charcot’s restraint orthotic walker (CROW) orthosis. Code L4631 is a custom fabricatedankle-foot orthosis which has all of the following characteristics:

1. Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and,2. Allows for varus or valgus deformity correction; and,


3. Contains a rocker bottom sole with a custom arch support; and,4. Incorporates a rigid anterior tibial shell; and,5. Used by a patient who is ambulatory; and,6. Has a soft interface.

Code L4631 includes all additions including straps and closures. No additional codes may be billed with code L4631.

Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2030, L2034, L2036-L2108, L2126-L2128and L4631 describe custom-fabricated orthoses. These codes must not be used for prefabricated (i.e., non-custom-fabricated) orthoses.

Codes L1902, L1906, L1910, L1930, L1951, L1971, L2035, L2112-L2116, and L2132-L2136 describe prefabricatedorthoses. These codes must not be used for custom-fabricated orthoses.

Codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are used for an ankle-foot orthosis whichis worn when a patient is ambulatory. Code L4396 is used for an ankle-foot orthosis which is worn when a patient isnonambulatory, or minimally ambulatory. Code L4398 is used for an ankle-foot orthosis which is worn when a patientis nonambulatory.

Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. For example,replacement soft interfaces used with ankle contracture orthoses or foot drop splints are billed with codes L4392and L4394, respectively. Replacement components that do not have a unique HCPCS code must be billed with a“not otherwise specified” code - L2999. HCPCS codes L4050-L4055 do not describe replacement soft interfacesused with contracture orthoses.

Code L4205 is used for the labor component of repair of a previously provided orthosis except for any laborinvolved in the replacement of an orthotic component that has a specific L code. It may only be billed for the actualtime involved in the repair of an orthosis. It must not be used for any labor involved in the evaluation, fabrication, orfitting of a new or full replacement orthosis. Labor involved in the replacement of an orthotic component that has aspecific L code is not separately billable.

Ankle-foot orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around thelower leg above the ankle. Foot orthotics are shoe inserts that do not extend above the ankle. The correct codes forfoot orthotics provided for patients without diabetes are L3000-L3090 (Refer to the Orthopedic Footwear policy formore information). Multiple density foot orthotics used in the management of diabetic foot problems are codedA5512 and A5513 (Refer to the Therapeutic Shoes for Persons with Diabetes policy for more information).

Claims for prefabricated or custom-fabricated devices that contain a concentric adjustable torsion style mechanismin the knee or ankle joint should be coded as E1810 (dynamic adjustable knee extension/flexion device, includessoft interface material) or E1815 (dynamic adjustable ankle extension/flexion device, includes soft interface material),respectively. All lines on claims billed with L-codes (i.e., L2861) for devices incorporating a concentric adjustabletorsion style mechanism in the knee or ankle joint will be rejected as incorrect coding.

Code A9283 (foot pressure off-loading/supportive device) is used for an item that is designed primarily to reducepressure on the sole or heel of the foot. It may be a shoe-like item, an item that is used inside a shoe and may ormay not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated.Code A9283 does not include items that meet the definition of a therapeutic shoe for diabetes(A5500, A5501).


Certain products may have both covered and non-covered uses, as defined by the Braces benefit category, andmust be coded based on the patient’s condition. For example, when used as a brace for the treatment of anorthopedic condition, walking boots are coded L4360 and L4386. However, walking boots must be coded A9283when used solely for the prevention or treatment of a lower extremity ulcer or pressure reduction.

When using code A9283, there is no separate billing using addition codes. Replacement liners for devices billedwith A9283 must be billed with code A9270 (noncovered item or service).

The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions, and replacement parts.When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on thesame claim line using the RTLT modifiers and 2 units of service. Claims billed without modifiers RT and/or LT will berejected as incorrect coding.

Evaluation of the patient, measurement and/or casting, and fitting of the orthosis are included in the allowance for theorthosis. There is no separate payment for these services.

Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to makethe orthosis functional. The reason for the repair must be documented in the supplier’s record. If the expense forrepairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for theamount in excess.

The allowance for the labor involved in replacing an orthotic component that is coded with a specific L code isincluded in the allowance for that component. The allowance for the labor involved in replacing an orthotic componentthat is coded with the miscellaneous code L4210 is separately payable in addition to the allowance for that component.

Addition codes L4002 – L4130, and L4392 are for billing of replacement components and are not payable at initialissue of a base orthosis. When claims for code(s) L4002 – L4130, and L4392 are billed at the time of initial issue ofa base orthosis, the addition code(s) will be rejected as incorrect coding.

Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correctcoding of these items.

A column II code must not be billed in addition to the corresponding column 1 code when provided at the same timefor the same limb.

Column I (Column II)L1900, L1910, L1920, L1980, L1990 (L4002, L4090, L4110)L2000-L2030 (L4002, L4070, L4080, L4090, L4100, L4110)L2034, L2036, L2037 (L4002, L4070)L2188 (L4002, L4020, L4030)L2320 (L4045, L4055)L2330 (L4040, L4050)L2335 (L4090)L2340 (L4130)L2510 (L4020)L2520 (L4030)L2530 (L4045)L2540 (L4040)L2550 (L4060)


CHAPTER DC: PCC GUIDELINES FOR AFO CODES

The PCC has sought to more clearly explain the different type of AFO codes that exist. We have suggested a fewadditional codes. The codes related to KFOs have not been listed, as they are beyond the scope of this document.

DESCRIPTION PCC Clarification

L1900 ANKLE FOOT ORTHO-SIS, SPRING WIRE, DORSI-FLEXION ASSIST CALFBAND, CUSTOM-FABRICATED

Custom fabricated AFO that incorporatesspring wire uprights attached to pins throughthe heel as a light weight aid to dorsiflexion.Spring wire technology permits transfer of theupright from shoe to shoe with mounting pinsembedded in the heel on the shoe.

L1901 ANKLE ORTHOSIS,ELASTIC, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT (E.G. NEO-PRENE, LYCRA)

Pre-fabricated AFO that is made of elasticbanding, encompassing the mid-foot andankle, and extending above the maleoli.

This design of AFO lacks any thermoplasticreinforcements. All support comes solely fromthe elastic material.

(NOTE: This code is discontinued effectiveJanuary 1, 2010 and crosswalked to A4466)

L1902 ANKLE FOOT ORTHO-SIS, ANKLE GAUNTLET,PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

Pre-fabricated AFO made of fabric and/or clothwith lace and/or hook-and-loop closure,encompassing the mid-foot and ankle, andextending above the maleoli.

This design of AFO lacks any thermoplasticreinforcements. All support comes solely fromthe fabric material.

L1904 ANKLE FOOT ORTHO-SIS, MOLDED ANKLE GAUNT-LET, CUSTOM-FABRICATED

Custom fabricated AFO made of leather orother suitable material with lace and/or hook-and-loop closure, encompassing the mid-footand ankle, and extending above the maleoli.

This design of AFO lacks any thermoplasticreinforcements. All support comes solely fromleather or other suitable material.

A4466 GARMENT, BELT,SLEEVE OR OTHER COVER-ING, ELASTIC OR SIMILARSTRETCHABLE MATERIAL,ANY TYPE, EACH (Note:Noncovered)

A9283 FOOT PRESSUREOFFLOADING/SUPPORTIVEDEVICE, ANY TYPE, EACH



L1906 ANKLE FOOT ORTHO-SIS, MULTILIGAMENTUSANKLE SUPPORT, PREFAB-RICATED, INCLUDES FITTINGAND ADJUSTMENT

Pre-fabricated AFO with rigid plastic medialand lateral upright supports connected byarticulating joints to a contoured footplate.

The medial and lateral supports are usuallypadded against the ankle and are connectedto one another around the calf with multiplehook-and-loop straps.

In this context, “multiligamentus” means that itsupports or controls one or more ligaments ofthe foot and ankle.

L1907 AFO,SUPRAMALLEOLAR WITHSTRAPS, WITH OR WITHOUTINTERFACE/PADS, CUSTOMFABRICATED

Custom fabricated AFO with rigid plasticdesign.

The first component is a plastic custom moldedshell that incorporates a foot plate and a highmedial and lateral walled foot orthosis thatextends just above the maleoli. Thiscomponent is usually padded with a softinterface material to protect the skin from therigid plastic.

The second component is a solid ankle footorthosis that extends to the calf and is closedaround the calf with a hook-and-loop strap.

These two components are usually combinedinto one device.

In designs where these two components areseparate, the first component will nest withinthe second component and be held in placeover the instep with a dorsal strap with hook-and-loop closure.

L1910 ANKLE FOOT ORTHO-SIS, POSTERIOR, SINGLEBAR, CLASP ATTACHMENT TOSHOE COUNTER, PREFABRI-CATED, INCLUDES FITTINGAND ADJUSTMENT

Prefabricated dorsi-assist AFO consisting of anupper calf band attached to a single semi-rigidposterior bar. The bar then attaches to theposterior portion of the shoe with a clip.



L1920 ANKLE FOOT ORTHO-SIS, SINGLE UPRIGHT WITHSTATIC OR ADJUSTABLESTOP (PHELPS ORPERLSTEIN TYPE), CUSTOM-FABRICATED

Custom fabricated AFO with leather calf bandattached to a single metal upright and stirrupplate with welded plate for range of motionadjustment.

L1930 ANKLE FOOT ORTHO-SIS, PLASTIC OR OTHERMATERIAL, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Prefabricated semi-rigid AFO made of plasticor similar material. This orthosis’ use can beeither weight bearing or non-weight bearing.

L1932 AFO, RIGID ANTERIORTIBIAL SECTION, TOTALCARBON FIBER OR EQUALMATERIAL, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Prefabricated anterior dorsi-assist AFO with arigid anterior tibial section with full foot plateand two calf band attachments with hook-and-loop closure. Must be made of carbon fiberor similar material.

L1940 ANKLE FOOT ORTHO-SIS, PLASTIC OR OTHERMATERIAL, CUSTOM-FABRI-CATED

Custom fabricated AFO made of plastic orsimilar material positioning the ankle in neutralplantarflexion or dorsiflexion position.



L1945 ANKLE FOOT ORTHO-SIS, PLASTIC, RIGID ANTE-RIOR TIBIAL SECTION(FLOOR REACTION), CUS-TOM-FABRICATED

L1950 ANKLE FOOT ORTHO-SIS, SPIRAL, (INSTITUTE OFREHABILITATIVE MEDICINETYPE), PLASTIC, CUSTOM-FABRICATED

Custom fabricated AFO made of plastic orsimilar material incorporating a molded archsection with spiral design around the calfattached to a hook-and-loop closure aroundthe leg.

In this instance, spiral design means a plasticupright material that starts on the lateral portionof the heel, just under the malleolus, and wrapsup and around the leg to the lateral calfattachment point with a hook-and-loop fastener.

L1951 ANKLE FOOTORTHOSIS, SPIRAL,(INSTITUTE OFREHABILITATIVE MEDICINETYPE), PLASTIC OR OTHERMATERIAL, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Pre-fabricated AFO made of carbon fibermaterial incorporating a molded arch sectionwith spiral design around the calf attached to ahook-and-loop closure around the leg.

In this instance, spiral design means an uprightmaterial that starts on the lateral portion of theheel, just under the malleolus, and wraps upand around the leg to the lateral calfattachment point with a hook-and-loop fastener.

L1960 ANKLE FOOT ORTHO-SIS, POSTERIOR SOLIDANKLE, PLASTIC, CUSTOM-FABRICATED

Custom fabricated AFO made of plastic orsimilar material, rigid design to hold the foot,ankle and lower leg in a fixed position, se-cured with a calf band fastener with hook-and-loop closure.

Custom fabricated rigid AFO made of plastic orsimilar material with a rigid upper leg anteriorsection in combination with a plastic foot plateincorporating the arch.



L1970 ANKLE FOOT ORTHO-SIS, PLASTIC WITH ANKLEJOINT, CUSTOM-FABRICATED

L1971 ANKLE FOOT ORTHO-SIS, PLASTIC OR OTHERMATERIAL WITH ANKLEJOINT, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Pre-fabricated AFO made of plastic or similarmaterial with articulated ankle joint used toconnect the arch/foot section with the upper legsection of the device, secured with a calf bandfastener with hook-and-loop closure. Thisdevice includes medial, lateral, and posteriorsupport in a more encompassing and stabiledesign than lesser codes (i.e. see L1906)

L1980 ANKLE FOOT ORTHO-SIS, SINGLE UPRIGHT FREEPLANTAR DORSIFLEXION,SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR ‘BK’ORTHOSIS), CUSTOM-FABRI-CATED

Custom fabricated AFO made of metal with asingle upright bar, medial or lateral attachmentto a separate stirrup. The top portion of theupright bar is attached to a metal calf band.The calf band is attached to the cuff. Thedevice is secured around the leg with a calfband fastener with hook-and-loop closure.

L1990 ANKLE FOOT ORTHO-SIS, DOUBLE UPRIGHT FREEPLANTAR DORSIFLEXION,SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR ‘BK’ORTHOSIS), CUSTOM-FABRI-CATED

Custom fabricated AFO made of metal with adouble upright bar, medial or lateral attachmentto a separate stirrup. The top portion of theupright bar is attached to a metal calf band.The calf band is attached to the cuff. Thedevice is secured around the leg with a calfband fastener with hook-and-loop closure.

Custom fabricated AFO made of plastic orsimilar material with articulated ankle joint usedto connect the arch/foot section with the upperleg section of the device, secured with a calfband fastener with hook-and-loop closure.



L2106 ANKLE FOOT ORTHO-SIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE CASTORTHOSIS, THERMOPLASTICTYPE CASTING MATERIAL,CUSTOM-FABRICATED

L2108 ANKLE FOOT ORTHO-SIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE CASTORTHOSIS, CUSTOM-FABRI-CATED

Custom fabricated fracture orthosis AFOcustom molded to a patient model.

L2112 ANKLE FOOT ORTHO-SIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE ORTHOSIS,SOFT, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Prefabricated fracture orthosis AFO made ofsoft thermoplastic material that attaches fromabove the maleoli to below the knee.

L2114 ANKLE FOOT ORTHO-SIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE ORTHOSIS,SEMI-RIGID, PREFABRI-CATED, INCLUDES FITTINGAND ADJUSTMENT

Prefabricated fracture orthosis AFO made ofsemirigid thermoplastic material that attachesfrom above the maleoli to below the knee.

Custom fabricated fracture orthosis AFOcustom molded to the patient’s affected area.

L2116 ANKLE FOOT ORTHO-SIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE ORTHOSIS,RIGID, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Prefabricated shell-type orthosis AFO made ofsemirigid thermoplastic material, with or withoutheel cup that attaches to below the knee.

L2200 ADDITION TO LOWEREXTREMITY, LIMITED ANKLEMOTION, EACH JOINT

Addition to custom fabricated AFO/stirrup: thatpart of the upright section comprising the ankleattachment, with the superior surface being flatto stop ankle motion.

L2210 ADDITION TO LOWEREXTREMITY, DORSIFLEXIONASSIST (PLANTAR FLEXIONRESIST), EACH JOINT

Addition to custom fabricated AFO/stirrup: thatpart of the upright section comprising the ankleattachment, with the superior surface beingcontoured to encourage dorsiflexion.



L2220 ADDITION TO LOWEREXTREMITY, DORSIFLEXIONAND PLANTAR FLEXIONASSIST/RESIST, EACH JOINT

L2230 ADDITION TO LOWEREXTREMITY, SPLIT FLATCALIPER STIRRUPS ANDPLATE ATTACHMENT

Addition to custom fabricated AFO/caliperplate: this device combines the box channelcaliper attachment to the shoe and the uprightear part of the stirrup. The superior surface ofthis type of upright could either be solid, dorsi-assist, free or limited.

L2232 ADDITION TO LOWEREXTREMITY ORTHOSIS,ROCKER BOTTOM FORTOTAL CONTACT ANKLEFOOT ORTHOSIS, FORCUSTOM FABRICATEDORTHOSIS ONLY

Addition to custom fabricated AFO: customdesigned roller/rocker bottom designed tolimit/stop ankle motion. The rear foot is rolledto reduce shock. Apex at midfoot to supportweight bearing. The forefoot is rolled topromote ambulation. Attached to the plantaraspect of a solid ankle, total contact, customfabricated AFO.

Addition to custom fabricated AFO/stirrup: thatpart of the upright section comprising the ankleattachment, with the superior surface beingcontoured to encourage dorsiflexion and resistplantarflexion.

L2240 ADDITION TO LOWEREXTREMITY, ROUND CALIPERAND PLATE ATTACHMENT

Addition to custom fabricated AFO/caliperplate: this device combines a round tubecaliper attachment to the shoe and the uprightear part of the stirrup. The superior surface ofthis type of upright could either be solid, dorsi-assist, free or limited.

L2250 ADDITION TO LOWEREXTREMITY, FOOT PLATE,MOLDED TO PATIENTMODEL, STIRRUP ATTACH-MENT

Addition to custom fabricated AFO, stirrupdesign: this device combines stirrup attach-ment to a custom foot plate design.



L2260 ADDITION TO LOWEREXTREMITY, REINFORCEDSOLID STIRRUP (SCOTT-CRAIG TYPE)

L2265 ADDITION TO LOWEREXTREMITY, LONG TONGUESTIRRUP

Addition to custom fabricated AFO/stirrup: thisdevice combines the upright section of thestirrup with a long tongue attachment surface.This design spreads out the weight bearingforces to decrease stress on the stirrup.

L2270 ADDITION TO LOWEREXTREMITY, VARUS/VALGUSCORRECTION (‘T’) STRAP,PADDED/LINED OR MALLEO-LUS PAD

Addition to custom fabricated AFO: strapdesigned to encourage varus/valgus correc-tion. Can be attached medially or laterally tothe shoe. Designed to be attached around theupright section of an AFO and the ankle.

Addition to custom fabricated AFO/stirrup: thisdevice combines a solid ankle design withadditional strut to reinforce the upright portionof the stirrup. The superior surface of this typeof upright could either be solid or plantarflexionor dorsiflexion design.

L2275 ADDITION TO LOWEREXTREMITY, VARUS/VALGUSCORRECTION, PLASTICMODIFICATION, PADDED/LINED

Addition to custom fabricated AFO: modifica-tion to include excavation, heat alteration, andpadding to control varus/valgus conditions.

L2280 ADDITION TO LOWEREXTREMITY, MOLDED INNERBOOT

Addition to custom fabricated AFO: interfaceportion of the AFO encompassing the midfoot,ankle and lower leg, Can be made of leather,plastic or foam materials. Designed to be thesupportive interface to the AFO.



L2320 ADDITION TO LOWEREXTREMITY, NON-MOLDEDLACER, FOR CUSTOMFABRICATED ORTHOSISONLY

L2330 ADDITION TO LOWEREXTREMITY, LACER MOLDEDTO PATIENT MODEL, FORCUSTOM FABRICATEDORTHOSIS ONLY

Addition to custom fabricated AFO: moldedAFO component of leather or similar materialmolded to patient model to encompass thecalf with lace or hook-and-loop closure. Thisdevice is typically referred to as a “calf lacer”and its hallmark is that it covers the calf.

L2340 ADDITION TO LOWEREXTREMITY, PRE-TIBIALSHELL, MOLDED TO PATIENTMODEL

Addition to custom fabricated AFO: componentfitting on the anterior portion of the leg (tibia)from the knee to six to eight inches above theankle complex. The design is intended tosupport the wearer’s weight at the base of theknee joint so as to reduce the forces on theankle and the plantar surface of the foot.

Addition to custom fabricated AFO: prefabri-cated AFO component of leather or similarmaterial to encompass the calf and/or lowerleg section with lace or hook-and-loop closure.

L2350 ADDITION TO LOWEREXTREMITY, PROSTHETICTYPE, (BK) SOCKET,MOLDED TO PATIENTMODEL, (USED FOR ‘PTB’‘AFO’ ORTHOSES)

Addition to custom fabricated AFO: plastic orsimilar material to encompass the calf or lowerleg section with lace or hook-and-loop closure.

L2360 ADDITION TO LOWEREXTREMITY, EXTENDEDSTEEL SHANK

See discussion at chapters BB and CE. Thisis a steel plate designed to be insertedbetween the midsole and outsole of the shoe.The purpose of the plate is to stop the sole ofthe shoe from bending. Must be molded byhand to follow the proper contour of the shoe.See also the suggestion of codes for carbon/prepreg shanks.

L2750 ADDITION TO LOWEREXTREMITY ORTHOSIS,PLATING CHROME ORNICKEL, PER BAR

Addition to custom fabricated AFO: any com-ponent metal converting the standard basealuminum charge to stainless steel, chrome ornickel plate.

L2755 ADDITION TO LOWEREXTREMITY ORTHOSIS, HIGHSTRENGTH, LIGHTWEIGHTMATERIAL, ALL HYBRID LAMINA-TION/PREPREG COMPOSITE,PER SEGMENT, FOR CUSTOMFABRICATED ORTHOSIS ONLY

See discussion at chapter BH. Addition tocustom fabricated AFO: any componentconverting the standard base material to highstrength, light weight materials of hybridlamination/ prepreg composites.



L2760 ADDITION TO LOWEREXTREMITY ORTHOSIS,EXTENSION, PER EXTEN-SION, PER BAR (FOR LINEALADJUSTMENT FOR GROWTH)

L2780 ADDITION TO LOWEREXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PERBAR

Addition to custom fabricated AFO: any mate-rial per bar or joint using power coating thatprovides a non-corrosive finish. This codeserves as an upgrade from the standardaluminum component.

L2820 ADDITION TO LOWEREXTREMITY ORTHOSIS, SOFTINTERFACE FOR MOLDEDPLASTIC, BELOW KNEESECTION

Addition to custom fabricated AFO: foam orpadded materials designed as cushion padsto the interior section to serve as a soft inter-face between the skin and the functional part ofthe device, sections of the leg below theknee.

Addition to custom fabricated AFO: designmodification so the design of the metal barsare drilled so that the length of the bars can beadjusted. This is normally used in devices forjuvenile patients to allow for growth.

L2830 ADDITION TO LOWEREXTREMITY ORTHOSIS, SOFTINTERFACE FOR MOLDEDPLASTIC, ABOVE KNEESECTION

Addition to custom fabricated AFO: foam orpadded materials designed as cushion padsto the interior section to serve as a soft inter-face between the skin and the functional part ofthe device, sections of the leg above theknee.

L2840 ADDITION TO LOWEREXTREMITY ORTHOSIS,TIBIAL LENGTH SOCK, FRAC-TURE OR EQUAL, EACH

A special below the knee sock that is worn withan orthosis to provide a protective/comfortableinterface between the skin and the device.

L2999 LOWER EXTREMITYORTHOSES, NOT OTHER-WISE SPECIFIED

Miscellaneous lower extremity code.

L4090 REPLACE METALBANDS KAFO-AFO, CALF ORDISTAL THIGH

Custom fabricated AFO repair/refurbishment.This code defines the replacement of thealuminum band that encircles the back of thecalf.

L4110 REPLACE LEATHERCUFF KAFO-AFO, CALF ORDISTAL THIGH

Custom fabricated AFO repair/refurbishment.This code defines the replacement of theleather cuff that circles the calf.

L4205 REPAIR OF ORTHOTICDEVICE, LABOR COMPO-NENT, PER 15 MINUTES

See the PCC discussion and suggestedcodes at chapters BJ and CK.



L4210 REPAIR OF ORTHOTICDEVICE, REPAIR OR RE-PLACE MINOR PARTS

L4350 ANKLE CONTROLORTHOSIS, STIRRUP STYLE,RIGID, INCLUDES ANY TYPEINTERFACE (E.G., PNEU-MATIC, GEL), PREFABRI-CATED, INCLUDES FITTINGAND ADJUSTMENT

Prefabricated AFO device comprised of astirrup design with rigid side panels and acushioned lining consisting of air/gel whichencompasses the lower leg while comingunder the ankle and calcaneous.

L4360 WALKING BOOT,PNEUMATIC OR VACUUM,WITH OR WITHOUT JOINTS,WITH OR WITHOUT INTER-FACE MATERIAL, PREFABRI-CATED, INCLUDES FITTINGAND ADJUSTMENT.

Prefabricated AFO, short leg walking boot, withair bladder(s) for adjustment, with or withoutjoints, with or without soft interface material.The device encompasses the lower leg andfoot.

See the PCC discussion and suggestedcodes at chapters BJ and CK.

L4386 WALKING BOOT, NON-PNEUMATIC, WITH OR WITH-OUT JOINTS, WITH OR WITH-OUT INTERFACE MATERIAL,PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

Prefabricated AFO, walking boot, with joints,with or without soft interface material. Thedevice encompasses the lower leg and foot.

Note: the PCC recognizes that there is adramatic manufacturing cost differential inmaking this device both with and without joints.The device should be split into two codes.See below:

Prefabricated AFO, walking boot, without joints,with or without soft interface material. Thedevice encompasses the lower leg and foot.



L4392 REPLACEMENT, SOFTINTERFACE MATERIAL,STATIC AFO

L4394 REPLACE SOFTINTERFACE MATERIAL, FOOTDROP SPLINT

Prefabricated AFO component. This coderepresents any replacement padding materialsfor a drop-foot AFO.

L4396 STATIC ANKLE FOOTORTHOSIS, INCLUDING SOFTINTERFACE MATERIAL,ADJUSTABLE FOR FIT, FORPOSITIONING, PRESSUREREDUCTION, MAY BE USEDFOR MINIMAL AMBULATION,PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

Prefabricated AFO component encompassingthe lower leg and foot and designed forpressure reduction in both dynamic and staticpositions.

Prefabricated AFO component. This coderepresents any replacement padding materialsfor a static AFO.

L4398 FOOT DROP SPLINT,RECUMBENT POSITIONINGDEVICE, PREFABRICATED,INCLUDES FITTING ANDADJUSTMENT

Prefabricated AFO that includes a rigid shellalong with a soft interface to be used in arecumbent or reclining position (i.e. non-ambulatory). The device encompasses thelower leg and foot and assists in controllingfoot drop.


SECTION D: AFO SERIES OF CODES - c.ymcdn.comc.ymcdn.com/.../resmgr/infodmepossupp/pcm_4_section_d-afoseriesofc.pdfSECTION D: AFO SERIES OF CODES. ... have begun to learn how to make,

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