Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.39o


Attachment:A

Policy #:05.00.39o

Description:HCPCS Codes

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.



MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT AFOs AND KAFOs FOR AMBULATORY INDIVIDUALS:

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, off-the-shelf

L1904 Ankle orthosis, ankle gauntlet or similiar, with or without joints, 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

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

L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf

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

L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf

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

THE FOLLOWING CODES ARE USED TO REPRESENT ADDITIONS TO AFOs OR KAFOs:

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

L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each

THE FOLLOWING CODES ARE USED TO REPRESENT REPAIRS OR REPLACEMENTS OF SHOES OR SHOES THAT ARE AN INTEGRAL PART OF AN EXISTING AFO OR KAFO:

L3224 Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthotic)

L3225 Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthotic)

THE FOLLOWING CODE IS USED TO REPRESENT SHOES THAT ARE AN INTEGRAL PART OF A COVERED BRACE:

L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified

THE FOLLOWING CODES ARE USED TO REPRESENT STATIC AFO FOR NONAMBULATORY (OR MINIMALLY AMBULATORY) INDIVIDUALS:

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 patient by an individual with expertise

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

THE FOLLOWING CODES ARE USED TO REPRESENT AFOs/ KAFOs USED FOR NIGHT SPLINTING IN CHILDREN WITH NEUROMUSCULAR DISORDERS/ ORTHOTIC MANAGEMENT AT REST SPLINTING:

L1960 Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated

L1970 Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated

L2035 Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment

THE FOLLOWING CODE IS USED TO REPRESENT CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISMS TO ASSIST KNEE JOINT EXTENSION AND/OR ANKLE JOINT PLANTAR FLEXION:

L2999 Lower extremity orthotic, not otherwise specified

THE FOLLOWING CODES ARE USED TO REPRESENT ALL OTHER REPAIRS OR REPLACEMENTS:

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

NOT MEDICALLY NECESSARY

L4394 Replace soft interface material, foot drop splint

L4398 Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf

NOT COVERED

A4467 Belt, strap, sleeve, garment, or covering, any type

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, eac

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

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