In the world of O&P billing, we are conditioned to expect a clear hierarchy: More clinical labor equals higher reimbursement. Since 2014, CMS has reinforced this by differentiating between off-the-shelf (OTS) and custom-fitted prefabricated items. The logic is simple: If patients can fit a brace themselves with minimal adjustment, the reimbursement is lower because the practitioners’ expertise isn’t “taxed.”
However, a closer look at the current fee schedule for AFOs reveals a head-scratching anomaly regarding codes L-1932 (AFO, rigid anterior shell, prefabricated, includes fitting and adjustment) and L-1933 (AFO, rigid anterior shell, prefabricated, OTS).
The Problem and the Paradox
Technically, L-1932 is the custom-fitted version. To bill it, a practitioner must provide and document “substantial modifications” beyond minimal adjustments. This requires detailed notes on what was modified, such as heat molding, trimming, or grinding, and clinical justification for why the patient or caregiver could not achieve a proper fit themselves.
Of course, clinical integrity remains paramount. In cases where only minimal modification was performed, we cannot and should not falsify documentation to qualify for a custom-fitted code. We must bill for the service actually provided. Yet, for those of us performing high-level clinical work, the “reward” feels strangely absent.
The Temptation of the OTS Path
The administrative divide between these two codes is widening. Perhaps most significantly, L-1932 now requires prior authorization, whereas L-1933 does not. This creates a massive incentive to bypass the clinical fitting altogether.
If you choose L-1932, you are opting into a heavy documentation burden, a mandatory wait for prior authorization, and the risk of an audit years down the line. If you choose L-1933, you can ship the device immediately, skip the fitting room, and avoid the additional administrative burden, all while receiving the exact same check from CMS.
Why Billing L-1933 Could be a Trap
If O&P providers nationwide shift to L-1933 simply because it is easier, we are effectively telling CMS that professional fitting is unnecessary. Once the data shows that the majority of these AFOs are being provided without practitioner intervention, CMS will have the “proof” they need to slash the reimbursement for L-1933. This path of least resistance is already being paved by large-scale DME companies.
Many DME businesses are owned by non-O&P practitioners who do not carry the same professional certifications, or the same clinical risks, as we do. These entities prefer a high-volume shipping model; they would much rather ship items nationwide and bill for prefabricated codes because it maximizes profit with zero clinical overhead.
Therefore, their claims and their actions may affect the entire industry; if the market becomes dominated by “shipped” claims, CMS will naturally move to lower the reimbursement to match a retail shipping model rather than a clinical one.
Conclusion
The identical fee schedule for L-1932 and L-1933 is a glitch, not a gift. By defaulting to L-1933 for convenience or to avoid the prior authorization hurdle, we are devaluing our own labor and handing the future of the industry to shipping-based DME providers. As practitioners, we must continue to document and bill for the actual level of care provided. It requires more work, but it is the only way to protect the clinical integrity of our profession.
Darya Shahrokhi, CPO, FAAOP, owns Pioneer Orthotics and Prosthetics, California.
