Movement Memo: Billing for Prefabricated AFOs
Medicare (CMS) has changed their definitions for custom fit orthoses. Learn how to avoid pesky audits and when to bill for L1951, L1932 or L2999.
The Takeaway
For prefabricated AFOs, you can be confident to bill under L1951 or L1932 if you have trimmed, bent, molded or otherwise modified the device to provide an individualized fit and documented it in your delivery note. Otherwise, you should bill under L2999.
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Updates to Medicare definitions
In October 2022, PDAC, Noridian and CGS updated their definitions of prefabricated orthoses and the proper coding for each category:
Custom Fit
Require more than minimal self-adjustment at the time of delivery in order to provide an individualized fit. The item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment. Adjustments require the expertise of a certified orthotist.
Off-the-shelf
Items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require the expertise of a certified orthotist or an individual with specialized training in the provision of orthotics.
What's the right code to use?
Traditional AFO L-codes L1951 and L1932 do not have an OTS equivalent for billing purposes. Therefore, without justification of substantial custom-fit modifications, it will require a clinician to use the L2999 when coding their devices:
- L2999 -- Lower extremity orthosis, not otherwise specified (NOS)
Miscellaneous codes do not have specific reimbursement amounts. Payers have various methods for determining payment amount when a miscellaneous code is submitted. Private payer contracts usually specify how miscellaneous codes are processed, using methods such a discount off of MSRP or a percentage of Billed Charges. Many times, this reimbursement amount will be less than a true custom fit code such as L1951 or L1932.
Billing for L2999 rather than L1951 or L1932 when no modifications have been performed can ensure that you are following the updated Medicare guidelines and protecting yourself from an audit.
How do I protect myself from an audit?
The simplest way to protect yourself from an audit is to ensure that you're compliant and up to date with the latest definitions by Medicare. Additionally you should:
- Write clear, detailed notes about any modifications you did to the device you delivered.
- Select prefabricated devices that can be trimmed, bent, or molded to provide an individualized fit
- Document the patient indications and your evaluation that led to the selection of this device over others
What does this mean for my practice?
Coding incorrectly can leave a practice at risk for audits. However, when designating L-codes for prefabricated devices, choosing products that clearly fit the "Custom Fit" definition will ensure that you can receive the highest allowable reimbursement. In many states, L2999, for example can be less than half the reimbursement as L1951 or L1932.
References:
- https://med.noridianmedicare.com/web/jadme/article-detail/-/view/6547796/billing-for-custom-fitted-orthotics-when-no-custom-fitting-is-completed-with-no-off-the-shelf-equivalent
- https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/2021/custom-fitted-orthotic-hcpcs-codes-without-a-corresponding-off-the-shelf-code-correct-coding
- https://med.noridianmedicare.com/web/jadme/dmepos/orthotics/correct-billing-for-custom-fitted-orthotics-when-no-custom-fitting-is-completed-with-no-off-the-shelf-equivalent
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Discover Elevate's Custom Fit AFOs
Our prefabricated, custom fit solutions provide an individualized fit for each patient. They can be trimmed, heat molded, and height adjusted to support the unique geometries of each patient.
Learn more about our products here.
