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Medicare Advisory Specifies A Height Requirement For Custom AFOs

CMS Policy Article, Effective January 2013

Arizona AFO

“Ankle-foot orthoses described by codes L1900, L1910-L1990 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 2-4 cm 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 – L1907.”;

Though not required for custom devices, manufacturers can submit devices to PDAC for verification to determine whether the AFO designs meet Medicare verification requirements.

Arizona AFO, has received HCPCS coding verification for the following products:

Arizona Extended L1960, L2330, L2820
Arizona Partial Foot L1940, L2330, L2820, L5000
Arizona Standard Short L1940, L2330, L2820
Arizona Standard Tall L1940, L2330, L2820
Arizona Unweighting L1960, L2330, L2820
Arizona Breeze L1940, L2330, L2820
Arizona Sporty L1940, L2330, L2820
Arizona Closed Toe Walker L1960, L2330, L2820, L3230, L3400
Arizona Neurowalker L1960, L2330, L2820, L3230, L3400
Moore Balance Brace L1940, L2330, L2820
Open Toe Walker L1960, L2330, L2820, L3230, L3400
Partial Foot Walker L1940, L2330, L2820, L3230, L3400, L5000
Thermoplastic AFO L1960
Thermoplastic Articulated AFO L1970
Thermoplastic Articulated AFO, Dorsi-Assist L1970, L2210
Split Upright AFO L2999
Split Upright AFO, Dorsi-Assist L2999

As stated on the PDAC website, “the assignment of a HCPCS code to the product(s) should in now way be construed as an approval or endorsement of the product(s) by the PDAC, DME MACs or Medicare, nor does it imply or guarantee claim reimbursement.”

The APMA, together with AOPA, is contesting the new definition as it brings into question the appropriateness of billing the popular double upright, hinged type plastic AFO using the L1970 and L2210 codes.

Clarification from the DME MAC medical directors is expected soon.