The four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have revised their respective policy articles (PAs)for AFOs/KAFOs. The PAs included a height requirement for AFO codes L-1900 and L-1910-1990. According to Centers for Medicare & Medicaid Services (CMS) coding guidelines, these AFOs “extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. The terminal height of an AFO shall be located between the proximal border of the gastrocnemius and the apex of the head of the fibula (a region that is generally 2-4cm distal to the apex of the head of the fibula). These features distinguish them from foot orthotics, which are shoe inserts that do not extend above the ankle and ankle gauntlets described by codes L1902-1907.”
With this revision, the terminal height requirement has been removed.
Because of the height requirement with these particular AFOs, some patients would have received a more restrictive and cumbersome device, extending almost to the knee, when a shorter one would have been effective. While “there are certainly times when a full AFO is required,” said Séamus Kennedy, BEng(Mech), CPed, “There are plenty of studies demonstrating that shorter AFOs are also very effective when addressing certain diagnoses such as posterior tibial tendon dysfunction (PTTD), lateral ankle instability, and degenerative joint disease(DJD).” In addition, the original policy articles “created much confusion regarding how high AFOs need to extend to qualify for Medicare coverage,” according to a letter from Josh White, DPM, CPed, posted January 11, 2013, to Podiatry Management Online.
The effective date for the revised PAs is for dates of service on or after January 1, 2013. Specifically, the following L-Codes are affected by the revision:
- L-1900: Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom-fabricated.
- L-1910: Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment.
- L-1920: Ankle foot orthosis, single upright with static or adjustable stop (Phelps or Perlstein type), custom-fabricated.
- L-1930: Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment.
- L-1932: Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment.
- L-1940: Ankle foot orthosis, plastic or other material, custom-fabricated.
- L-1945: Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom-fabricated.
- L-1950: Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic, custom-fabricated.
- L-1951: Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment.
- L-1960: Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated.
- L-1970: Ankle foot orthosis, plastic with ankle joint, custom-fabricated.
- L-1971: Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment.
- L-1980: Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom-fabricated.
- L-1990: Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom-fabricated.
The following is a list, by Jurisdiction, of the affected PAs and their corresponding local coverage determination (LCD) articles.
- Jurisdiction A, NHIC: PA A19806 and
LCD L11527. - Jurisdiction B, National Government Services (NGS): PA A47227.
and
LCD 27229. - Jurisdiction C, CGS Administrators: PA A19885
and
LCD L11517 . - Jurisdiction D, Noridian Administrative Services (NAS): PA A19800
and LCD L142
.
Include image AFO
