The Pricing, Data Analysis, and Coding (PDAC) contractor for the Centers for Medicare & Medicaid Services (CMS) has posted clarified definitions for certain AFOs to assist suppliers in the correct coding of these devices. This information will be added to a future revision of the AFO local coverage determination (LCD) and related policy article.
L-2340: Addition to Lower Extremity, Pre-Tibial Shell, Molded To Patient Model.
A pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.
L-1906: Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Includes Fitting and Adjustment.
A multiligamentous ankle support provides control of the ankle joint between the medial and lateral malleoli while allowing for dorsiflexion and plantar flexion. This off-the-shelf ankle support includes a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation. This, in conjunction with wrap-around straps and the inherent gauntlet design, offers areas of multiligamentous support as described by the code. There are no additional HCPCS codes for this type of prefabricated ankle orthosis.
L-1960: Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom-Fabricated.
An ankle foot orthosis (AFO) provides ankle control for patients with musculoskeletal or neuromuscular dysfunction. The AFO is designed to provide rigid immobilization of the ankle-foot complex in the sagittal, coronal, and transverse planes. The custom fabricated solid ankle AFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. The proximal boarder of an ankle foot orthosis (L-1960) shall extend to a height no greater than 1.5 inches distal to the apex of the head of the fibula.
Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L-1906 are those for which a written coding verification has been made by the PDAC contractor and that are listed in the Product Classification Matrix of the Durable Medical Equipment Coding System (DMECS) maintained on the PDAC website. Products which have not received coding verification review from the PDAC must be billed with code A-9270.
