Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article - Effective October 2015

Revision Effective Date: 10/01/2026
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: L1972 to the prefabricated orthoses HCPCS codes
CODING GUIDELINES:
Added: A row to the table that pertains to corresponding sets of HCPCS codes; the added row contains L1971 in Column I and L1972 in Column II
Added: L1972 to the HCPCS codes for ankle-foot orthoses that extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle
Revised: Long description of L1971
Added: Coding guideline information for L1972
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: M72.2 from Group 1 Codes, due to ICD-10-CM code updates
Added: M67.A01 and M67.A02 to Group 1 Codes, due to ICD-10-CM code updates
10/01/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2026
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary.” to “Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of why the modifications are necessary and what modifications were performed at the time of fitting the orthosis to the beneficiary.,” as clarification
CODING GUIDELINES:
Added: Coding guideline information for L2221


04/09/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2025
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner.” as clarification
Added: HCPCS codes L1933 and L1952 to the prefabricated orthoses HCPCS codes
CODING GUIDELINES:
Added: A row to the table that pertains to corresponding sets of HCPCS codes; the added row contains “L1932” in Column I and “L1933” in Column II
Added: A row to the table that pertains to corresponding sets of HCPCS codes; the added row contains “L1951” in Column I and “L1952” in Column II
Added: HCPCS codes L1933 and L1952 to the HCPCS codes for ankle-foot orthoses that extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle
Revised: Coding guidelines for HCPCS codes L1932, L1951, and L1971
Added: Coding guidelines for HCPCS codes L1933 and L1952
CODING VERIFICATION REVIEW:
Added: Coding verification review information for HCPCS code L1952, effective for dates of service on or after April 1, 2025


04/03/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2025
CODING GUIDELINES:
Revised: Long descriptions for HCPCS codes E1810 and E1815
Added: HCPCS codes E1813 and E1814 to the HCPCS codes noted as codes for durable medical equipment that are used when coding claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint for any condition other than an assistive function to joint extension motion
Added: HCPCS codes E1822 and E1823 to the HCPCS codes noted as codes for durable medical equipment that are used when coding claims for devices that contain a concentric adjustable torsion style mechanism in the ankle joint for any condition other than an assistive function to joint plantar- or dorsiflexion motion
01/16/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/23/2024
CODING VERIFICATION REVIEW:
Added: Coding verification review information for HCPCS code L1951, effective for DOS on or after 12/01/2024
06/06/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/23/2024
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: “Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS.”
CODING GUIDELINES:
Added: “Use of an additive manufacturing technique, CAD/CAM, or a similar manufacturing technique is not the sole requirement for a product to be designated as custom fabricated.”
Removed: “An orthosis that is fabricated from a mold, CAD/CAM, or similar technology but without the creation of a positive model is considered a prefabricated orthosis.”
Added: “Additive Manufacturing” with a description
Added: “Additive manufacturing is an acceptable custom fabrication technique as long as it adheres to the CMS DMEPOS Quality Standards, Appendix C.”
Removed: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as OTS if the final fitting upon delivery to the patient requires minimal self-adjustment not requiring expertise as described in this section.”
Removed: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.”


03/07/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Language that describes prefabricated and custom fabricated orthoses
Revised: “This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training.” to “This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training (as defined in the CODING GUIDELINES section).”
Revised: HCPCS referenced as custom fabricated orthoses, to include “L1900”
Revised: “This information will be corroborated by the functional evaluation in the orthotist or prosthetist’s records.” to “This information will be corroborated by the functional evaluation in the orthotist’s records and the method of custom fabrication should adhere to the DMEPOS Quality Standards, Appendix C.”
MODIFIERS:
Removed: “refer to the CODING GUIDELINES section for additional information” pertaining to RT and LT modifiers
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
MISCELLANEOUS:
Added: “(Refer to the REPAIR/REPLACEMENT section for more information regarding billing of L4205 and L4210 HCPCS codes.)”
CODING GUIDELINES:
Added: “CUSTOM FABRICATED”
Added: “Custom-fabricated additions are appropriate only for custom-fabricated base orthotics and should not be billed with prefabricated base orthotics” (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: Language that describes custom fabricated orthoses, molded-to-patient-model custom fabrication, and positive model of the patient
Added: “Specialized Training” and the definition of specialized training
Added: “PREFABRICATED” and language that describes prefabricated orthoses
Removed: “However, for certain types of orthoses, the HCPCS code narrative that best describes the product does not make a distinction between prefabricated orthoses that are provided as custom-fit or OTS. These code narratives are correct and must be used for Medicare billing, without regard to how the product is provided to the beneficiary at the final delivery.” (Effective March 11, 2021)
Added: “Corresponding HCPCS Code Sets”
Revised: “parallel” to “corresponding” in regard to HCPCS codes
Removed: “(e.g., L4360, L4361, L4386, L4387, L4396 and L4397)” from the sentence that pertains to corresponding sets of HCPCS codes
Added: HCPCS codes L4360, L4361, L4386, L4387, L4396, and L4397 to a table that pertains to corresponding sets of HCPCS codes
Added: Information that pertains to the coding of a prefabricated orthosis when a corresponding HCPCS code set is not available and the unique HCPCS code describes a custom fitted item, including “Code the product using the unique HCPCS code, if the product was custom fitted at the time of delivery to the beneficiary” and “Code the product using a miscellaneous HCPCS code, if the product was not custom fitted at delivery to the beneficiary and, instead, was provided as OTS to the beneficiary. The miscellaneous HCPCS code for billing of AFOs and KAFOs is HCPCS code L2999.” (Effective March 11, 2021)
Revised: “Elastic and Similar Stretchable Materials” to “ELASTIC AND SIMILAR STRETCHABLE MATERIALS”
Added: “ANKLE-FOOT ORTHOSES,” “KNEE-ANKLE-FOOT ORTHOSES,” “POSITIONING DEVICES,” “SHOE INSERTS,” “CONCENTRIC TORSION JOINTS,” “WALKING BOOTS,” “OTHER DEVICES,” and “REPAIR/REPLACEMENT”
Added: Coding guideline information for HCPCS codes L2034, L2036, L2200, L2210, L2220, L2280, L2330, and L2820
Added: “LOWER EXTREMITY ADDITIONS” and language that describes custom-fabricated additions
Removed: Language that referred to the HCPCS codes which describe custom fabricated and prefabricated orthoses
Removed: Language that referred to the HCPCS codes which describe orthoses worn when a beneficiary is ambulatory, non-ambulatory, or minimally ambulatory
Revised: Language that pertains to shoes, inserts, and shoe modifications that are integral components of a leg brace and the pertinent HCPCS codes
Removed: RT and LT modifier information


12/07/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “Braces Benefit” to “braces benefit”
Revised: “Coding Guidelines” to “CODING GUIDELINES”
Revised: “Ankle-Foot Orthosis” to “ankle-foot orthosis”
Revised: “CAD-CAM” to “computer-aided design/computer-aided manufacturing (CAD/CAM)”
GENERAL REQUIREMENTS:
Revised: “Coding Guidelines” to “CODING GUIDELINES”
Revised: “off-the-self” to “OTS”
MODIFIERS:
Revised: “KX, GA, and GZ MODIFIERS:” to “GA, GZ, KX, LT and RT MODIFIERS:”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Revised: Language describing parallel code set availability for identical types of products
Revised: Coding guideline language for HCPCS codes L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, and L2006
Revised: Coding guideline information for HCPCS codes L1910, L1932, and L1951, to include that there are no additional HCPCS codes for these types of orthoses
Added: Long HCPCS descriptions to coding guidelines for HCPCS codes L2006, L2340, and L2755
Revised: Language describing the coding of foot orthotics as L-codes or A-codes
Revised: “Durable Medical Equipment” to “durable medical equipment”
Revised: “Braces” to “braces”
Revised: Format of long HCPCS descriptions for HCPCS codes A9270 and L4205
05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list
04/14/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
CODING GUIDELINES:
Removed: Coding verification review information for HCPCS codes L1906 and L2006
CODING VERIFICATION REVIEW:
Added: Section header and PDAC coding verification review information
Added: Coding verification review information for HCPCS codes L1906 and L2006
03/11/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Prefabricated orthoses (OTS or custom-fit) incorrect coding denial language, by removing “with a statutory denial”
Added: Definitions of prefabricated and custom fabricated orthoses
Clarified: Billing of custom fabricated additions
CODING GUIDELINES:
Added: Coding guideline information for HCPCS code L2005

11/19/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2020
MISCELLANEOUS:
Clarified: Custom fabricated items that do not have specific HCPCS codes require additional information in claim narrative
Added: Statement referring to the LCD-related Standard Documentation Requirements article for more information
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: Non-specific ICD-10 codes M24.573 and M24.576 from Group 1 codes
Removed: Non-specific ICD-10 code M14.679 from Group 2 codes
09/24/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 07/01/2020
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10 diagnosis codes E08.610, E09.610, E10.610, and E11.610 to Group 2 Codes for L4631
06/04/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “ordering physician’s” to “treating practitioner’s”
Revised: “physician’s” to “practitioner’s”
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
CODING GUIDELINES:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Added: Coding Guidelines for L1900, L1902, L1904, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1970, L1971, L1980, and L1990
Revised: L1906 Coding Guideline
Revised: L2006 Coding Guideline per quarterly HCPCS code update
Removed: HCPCS K0903
Added: HCPCS A5514, crosswalk from K0903
Removed: Reference of effective DOS for K0903
Added: Reference of effective DOS for A5514

02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
 Added: L2006 Coding Guideline
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


12/19/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Clarified: Custom fit requirements
Revised: Coding instructions for prefabricated orthoses without distinction of OTS or custom-fit.
Revised: RT and LT modifier billing instructions (Effective 03/01/2019)
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding unlisted diagnosis codes from coverage for specific HCPCS codes. Notation that for all other HCPCS codes, diagnoses are not specified.

03/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
CODING GUIDELINES:
Revised: Code pairs to accurately reflect parallel codes
Updated: HCPCS code narratives to align with HCPCS code table
Added: Walking boot add-on bundling information


04/05/2018:  At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date:  01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Brace Benefit explanation to remove reference to “counterforce” that is no longer applicable
Revised: Prefabricated and off-the-shelf (OTS) “minimal self-adjustment” regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment
Deleted: A4466
Added: A4467
Added: Instructions for A9285
Added: Policy specific documentation requirements from LCD
CODING GUIDELINES:
Removed: Reference to classification algorithm summary
Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of “minimal self-adjustment”
Added: Section on coding of elastic and similar materials
Deleted: A4466
Added: A4467
Added A9285
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 01/01/2016
CODING GUIDELINES:
Added: L4361 “clerical correction”

Revision Effective Date: 01/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Information for hospital and SNF reimbursement
CODING GUIDELINES:
Added: Reference to classification algorithm summary