Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA05.010d


Attachment:A

Policy #:MA05.010d

Description:HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS

Title:Ankle-Foot/Knee-Ankle-Foot Orthoses


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS


TABLE 1: MEDICALLY NECESSARY AFOs AND KAFOs WITH CRITERIA

THE FOLLOWING CODES REPRESENT AFOS AND KAFOS FOR AMBULATORY INDIVIDUALS
HCPCS
CODE
NARRATIVE
AFOs
L1900
Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf band, custom fabricated
L1902
Ankle orthosis, ankle gauntlet or similiar, with or without joints, prefabricated, off-the-shelf
L1904
Ankle orthosis, ankle gauntlet, custom-fabricated
L1906
Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf
L1907
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated
L1910
Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment
L1920
Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated
L1930
Ankle-foot orthotic (AFO), plastic or other material, prefabricated, includes fitting and adjustment
L1932
Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment
L1940
Ankle-foot orthotic (AFO), plastic or other material, custom fabricated
L1945
Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated
L1950
Ankle-foot orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated
L1951
Ankle-foot orthotic (AFO), spiral, (Institute of rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment
L1960
Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated
L1970
Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated
L1971
Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, includes fitting and adjustment
L1980
Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'BK' orthotic), custom fabricated
L1990
Ankle-foot orthotic (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'BK' orthotic), custom fabricated
L4361
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf
L4387
Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf
KAFOs
L2000
Knee-ankle-foot orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthotic), custom fabricated
L2005
Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated
L2010
Knee-ankle-foot orthotic (KAFO), single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthotic), without knee joint, custom fabricated
L2020
Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthotic), custom fabricated
L2030
Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthotic), without knee joint, custom fabricated
L2034
Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated
L2035
Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment
L2036
Knee-ankle-foot orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated
L2037
Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated
L2038
Knee-ankle-foot orthotic (KAFO), full plastic, with or without free motion knee, multi-axis ankle, custom fabricated
L2106
Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, thermoplastic type casting material, custom fabricated
L2108
Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, custom fabricated
L2112
Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, soft, prefabricated, includes fitting and adjustment
L2114
Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, semi-rigid, prefabricated, includes fitting and adjustment
L2116
Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, rigid, prefabricated, includes fitting and adjustment
L2126
Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, thermoplastic type casting material, custom fabricated
L2128
Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, custom fabricated
L2132
Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, soft, prefabricated, includes fitting and adjustment
L2134
Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, semi-rigid, prefabricated, includes fitting and adjustment
L2136
Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, rigid, prefabricated, includes fitting and adjustment
L4350
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf
L4360
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4370
Pneumatic full leg splint, prefabricated, off-the-shelf
L4386
Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4631
Ankle-foot orthotic, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated
TO REPORT ADDITIONS TO AFOs OR KAFOs, USE THE FOLLOWING CODES
L2180
Addition to lower extremity fracture orthotic, plastic shoe insert with ankle joints
L2182
Addition to lower extremity fracture orthotic, drop lock knee joint
L2184
Addition to lower extremity fracture orthotic, limited motion knee joint
L2186
Addition to lower extremity fracture orthotic, adjustable motion knee joint, Lerman type
L2188
Addition to lower extremity fracture orthotic, quadrilateral brim
L2190
Addition to lower extremity fracture orthotic, waist belt
L2192
Addition to lower extremity fracture orthotic, hip joint, pelvic band, thigh flange, and pelvic belt
L2200
Addition to lower extremity, limited ankle motion, each joint
L2210
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
L2220
Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
L2230
Addition to lower extremity, split flat caliper stirrups and plate attachment
L2232
Addition to lower extremity orthotic, rocker bottom for total contact ankle-foot orthotic (AFO), for custom fabricated orthotic only
L2240
Addition to lower extremity, round caliper and plate attachment
L2250
Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
L2260
Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)
L2265
Addition to lower extremity, long tongue stirrup
L2270
Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
L2280
Addition to lower extremity, molded inner boot
L2300
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
L2310
Addition to lower extremity, abduction bar, straight
L2320
Addition to lower extremity, nonmolded lacer, for custom fabricated orthotic only
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthotic only
L2335
Addition to lower extremity, anterior swing band
L2340
Addition to lower extremity, pretibial shell, molded to patient model
L2350
Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB," "AFO" orthoses)
L2360
Addition to lower extremity, extended steel shank
L2370
Addition to lower extremity, Patten bottom
L2375
Addition to lower extremity, torsion control, ankle joint and half solid stirrup
L2380
Addition to lower extremity, torsion control, straight knee joint, each joint
L2385
Addition to lower extremity, straight knee joint, heavy duty, each joint
L2387
Addition to lower extremity, polycentric knee joint, for custom fabricated knee-ankle-foot orthotic (KAFO), each joint
L2390
Addition to lower extremity, offset knee joint, each joint
L2395
Addition to lower extremity, offset knee joint, heavy duty, each joint
L2397
Addition to lower extremity orthotic, suspension sleeve
L2405
Addition to knee joint, drop lock, each
L2415
Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint
L2425
Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
L2430
Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
L2492
Addition to knee joint, lift loop for drop lock ring
L2500
Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring
L2510
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model
L2520
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted
L2525
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model
L2526
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted
L2530
Addition to lower extremity, thigh/weight bearing, lacer, nonmolded
L2540
Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model
L2550
Addition to lower extremity, thigh/weight bearing, high roll cuff
L2750
Addition to lower extremity orthotic, plating chrome or nickel, per bar
L2755
Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only
L2760
Addition to lower extremity orthotic, extension, per extension, per bar (for lineal adjustment for growth)
L2768
Orthotic side bar disconnect device, per bar
L2780
Addition to lower extremity orthotic, noncorrosive finish, per bar
L2785
Addition to lower extremity orthotic, drop lock retainer, each
L2795
Addition to lower extremity orthotic, knee control, full kneecap
L2800
Addition to lower extremity orthotic, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthotic only
L2810
Addition to lower extremity orthotic, knee control, condylar pad
L2820
Addition to lower extremity orthotic, soft interface for molded plastic, below knee section
L2830
Addition to lower extremity orthotic, soft interface for molded plastic, above knee section
THE FOLLOWING CODE IS USED TO REPRESENT CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISMS USED TO ASSIST KNEE JOINT EXTENSION AND/OR ANKLE JOINT PLANTAR FLEXION
L2999
Lower extremity orthotic, not otherwise specified
TO REPORT ALL OTHER REPAIRS OR REPLACEMENTS, USE THE FOLLOWING CODES
L4002
Replacement strap, any orthotic, includes all components, any length, any type
L4010
Replace trilateral socket brim
L4020
Replace quadrilateral socket brim, molded to patient model
L4030
Replace quadrilateral socket brim, custom fitted
L4040
Replace molded thigh lacer, for custom fabricated orthotic only
L4045
Replace nonmolded thigh lacer, for custom fabricated orthotic only
L4050
Replace molded calf lacer, for custom fabricated orthotic only
L4055
Replace nonmolded calf lacer, for custom fabricated orthotic only
L4060
Replace high roll cuff
L4070
Replace proximal and distal upright for KAFO
L4080
Replace metal bands KAFO, proximal thigh
L4090
Replace metal bands KAFO-AFO, calf or distal thigh
L4100
Replace leather cuff KAFO, proximal thigh
L4110
Replace leather cuff KAFO-AFO, calf or distal thigh
L4130
Replace pretibial shell
L4205
Repair of orthotic device, labor component, per 15 minutes
L4210
Repair of orthotic device, repair or replace minor parts
L4392
Replacement soft interface material, static AFO
TO REPORT STATIC AFO FOR NONAMBULATORY (OR MINIMALLY AMBULATORY) INDIVIDUALS, USE THE FOLLOWING CODE
L4396
Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific
L4397
Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

TABLE II: NOT MEDICALLY NECESSARY LOWER EXTREMITY ORTHOSES AND ASSOCIATED ADDITIONS AND SERVICES

THE FOLLOWING CODES ARE CONSIDERED NOT MEDICALLY NECESSARY
HCPCS
CODE
NARRATIVE
L4394
Replace soft interface material, foot drop splint
L4398
Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf

TABLE III: NOT COVERED ADDITIONS TO LOWER EXTREMITY ORTHOSES

THE FOLLOWING CODES ARE CONSIDERED NOT COVERED
HCPCS
CODE
NARRATIVE
A4467
Belt, strap, sleeve, garment, or covering, any type
A9283
Foot pressure off loading/supportive device, any type, each
A9285
Inversion/eversion correction device
L2840
Addition to lower extremity orthotic, tibial length sock, fracture or equal, each
L2850
Addition to lower extremity orthotic, femoral length sock, fracture or equal, each
L2861
Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each (Duplicate)
THE FOLLOWING CODE IS USED TO REPRESENT REPLACEMENT LINERS, BILLED WITH CODE A9283 (FOOT PRESSURE OFF-LOADINGF/SUPPORTIVE DEVICES)
L2999
Lower extremity orthotic, not otherwise specified


Version Effective Date: 01/26/2018
Version Issued Date: 01/26/2018
Version Reissued Date: 09/25/2019

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