L-Codes for OTS vs. Custom Fit Ankle Foot Orthosis (AFO)

Ankle Foot Orthoses fall into three different categories:

OR01: Orthotic devices, custom fabricated

• Custom fabricated, includes fitting and adjustment

OR02: Orthotic devices: prefabricated (custom fit) 

• Prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• Prefabricated, includes fitting and adjustment

OR03: Orthoses: off-the-shelf

• Prefabricated, off-the-shelf

‍

As part of the 2014 and 2015 HCPCS update, codes were created for certain off-the-shelf orthoses. However, there are certain HCPCS codes categorized as custom fit orthotic devices because there are no corresponding off-the-shelf codes. It is important to note that if a prefabricated orthosis is categorized as custom fit but delivered as off-the-shelf (OTS) and there is no corresponding OTS code, then a miscellaneous code must be used to bill.

‍

OTS Orthoses

• Items that are prefabricated
• Require minimal self-adjustment for fitting at the time of delivery and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual
• This fitting does not require the expertise of a Certified Orthotist or an individual who has specialized training in the provision of orthotics to fit the item to the individual

‍

Custom Fit orthoses

• Devices that are prefabricated 
• Classification requires more than minimal self-adjustment, the item must be trimmed, bent, molded, or otherwise modified resulting in alterations beyond minimal self-adjustment
• This fitting at delivery requires the expertise of a Certified Orthotist or an individual who has specialized training.
• These items cannot be mailed or shipped to the beneficiary without prior custom fitting of the item.
• 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. This information must be available upon request.

‍

For example, a clinician has a multiple sclerosis patient that is recently diagnosed with drop foot. The patient experiences mild to moderate dorsiflexion weakness but no plantarflexion weakness, and after evaluation, the orthotist fits the patient with a posterior carbon fiber afo brace. The patient is fit with a size small, however, the product required minimal adjustment and did not require any customizing. The orthotist billed this as a miscellaneous code:

[L2999 - Lower extremity orthoses, not otherwise specified]

‍

That same day, the orthotist saw another patient who was diagnosed with cerebral palsy many years ago and had been wearing a custom fabricated, thermoplastic afo. However, the patient experiences moderate ankle dorsiflexion weakness, spasticity, and plantarflexion weakness. After evaluation the orthotist fits the patient with an prefabricated, anterior carbon fiber afo. The orthotist customized the product by trimming the footplate, adjusting the calf height, and assembling the product. The orthotist billed this as a custom fitted code:

[L1932 - AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment]

‍

Prefabricated custom fit orthotic devices without an OTS equivalent:

• L1932
• L1951 

‍

Please refer to the HCPCS Code Table. 

‍

Custom fitting requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual.

‍

How to Decide What Code Type for Prefabricated Orthotic

‍