Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)

Designed to maintain the foot at a fixed position of 0 (i.e., perpendicular to the lower leg); and,Allows for varus or valgus deformity correction; and,Contains a rocker bottom sole with a custom arch support; and,Incorporates a rigid anterior tibial shell; and,Used by a beneficiary who is ambulatory; and,Has a soft interfaceTotally encapsulated.Code L4631 includes all additions including straps and closures. No additional codes may be billed with code L4631.KNEE-ANKLE-FOOT ORTHOSESL2005 (KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, ANY TYPE ACTIVATION, INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED) describes a custom fabricated, single or double upright KAFO with an automatic lock and swing phase release knee joint. Automatic knee lock is activated by any method such as mechanical or electrical. The custom fabricated KAFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. It includes any type ankle joint and closure components. There are no additional add-on codes for L2005. This KAFO is custom fabricated per the DMEPOS Quality Standards, Appendix C.L2006 (KNEE ANKLE FOOT DEVICE, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, SWING AND STANCE PHASE MICROPROCESSOR CONTROL WITH ADJUSTABILITY, INCLUDES ALL COMPONENTS (E.G., SENSORS, BATTERIES, CHARGER), ANY TYPE ACTIVATION, WITH OR WITHOUT ANKLE JOINT(S), CUSTOM FABRICATED) describes a custom fabricated, single or double upright KAFO with an adjustable microprocessor control feature which provides resistance to stance and swing phase knee joint motion. The custom fabricated KAFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. There are no additional add-on codes for this KAFO. This KAFO is custom fabricated per the DMEPOS Quality Standards, Appendix C.L2034 (KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED) describes a custom fabricated, single upright KAFO designed to control (1) knee flexion, extension, and rotation motions (2) ankle inversion, eversion, dorsiflexion, plantarflexion, and rotation motions of the ankle foot complex. Primary construction is a rigid shell-like or equal structure which can be; (1) with or without free range of motion knee hinge or joint mechanism; (2) with or without free range of motion ankle hinge(s). Through a series of straps/supports that cross over and around the knee joint, rotational control and varus or valgus force is exerted on the knee joint. Structure contacts thigh, calf, lower leg, and foot to provide control. Foot plate must extend to the metatarsal heads. The custom fabricated KAFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. Included in the code are closure components. The predicate product is the Generation II KAFO with hinged ankle manufactured by Generation II USA, Inc. This KAFO is custom fabricated per the DMEPOS Quality Standards, Appendix C.L2036 (KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED) describes a custom fabricated, double upright KAFO designed to control (1) knee flexion, extension, rotation motions (2) ankle inversion, eversion, dorsiflexion, plantarflexion, and rotation motions of the ankle foot complex. Primary construction is a rigid shell-like or equal structure which can be with or without free range of motion hinge or joint mechanisms at the knee and/or ankle. Structure contacts thigh, calf, lower leg, and foot to provide control. Foot plate must extend to the metatarsal heads. The custom fabricated KAFO can be constructed from thermosetting materials, thermoplastics, or composite type materials. Included in the code are closure components. This KAFO is custom fabricated per the DMEPOS Quality Standards, Appendix C.LOWER EXTREMITY ADDITIONSCustom-fabricated additions are appropriate only for custom-fabricated base orthotics and should not be billed with prefabricated base orthotics unless a product has been previously assigned an addition code per PDAC/CMS prior to 1/1/2023. Correct coding with use of addition codes should not include, or partially include, features or functions described by other codes billed for a specific device.L2200 (ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT) describes an ankle joint product which can control dorsiflexion and/or plantarflexion of the ankle joint. The range of motion is set during fabrication. Joints can be deployed as a pair (two UOS) or singly (one UOS) with appropriate custom fabricated AFO or KAFO. Product will be distinctly identifiable from other components of the orthosis.L2210 (ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT) describes an ankle joint product which can control plantarflexion of the ankle joint. The range of motion is adjustable post-delivery of the orthosis. Initial setting is set by the supplier during fabrication. Joints can be deployed as a pair (two UOS) or singly (one UOS) with appropriate custom fabricated AFO or KAFO. Product will be distinctly identifiable from other components of the orthosis.L2220 (ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT) describes an ankle joint product which can control dorsiflexion and/or plantarflexion of the ankle joint. The range of motion is adjustable post-delivery of the orthosis. Initial setting is set by the supplier during fabrication. Joints can be deployed as a pair (two UOS) or singly (one UOS) with appropriate custom fabricated AFO or KAFO. Product will be distinctly identifiable from other components of the orthosis.L2280 (ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT) describes a custom molded device which encircles the ankle and to at least the mid-foot to provide multi-directional support to the ankle foot complex with compression from semi-rigid or rigid material(s). Inner boot is fully circumferential with closure components included such as lacing/eyelets or hook/loop. Lacer material and construction must conform to DMEPOS Quality Standards, Appendix C.L2330 (ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY) describes an upgrade to the cuff (including closures) to cover the rigid structures of the orthosis. Custom fabrication would capture shapes and contours of the anatomy to improve function of the included cuff/closure component. Lacer is fully circumferential with closure components included such as lacing/eyelets or hook/loop. Lacer material and construction must conform to DMEPOS Quality Standards, Appendix C.L2340 (ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL) is a pre-tibial shell, custom fabricated, that provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.Code L2755 (ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY) describes an addition to a lower extremity orthosis composed of high strength and/or lightweight material such as Kevlar, carbon fiber or other laminated or impregnated composite material.L2820 (ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION) describes a moldable and compliant material which has been fabricated as an integral part of a custom fabricated orthosis. The interface is designed to allow cushioning and contouring over pressure-sensitive areas of the limb in greater capacity than what may be included in the base orthosis that is constructed from thermosetting materials, thermoplastics, or composite type materials. The soft interface material and construction must conform to DMEPOS Quality Standards, Appendix C.POSITIONING DEVICESA non-ambulatory ankle-foot orthosis may be either an ankle contracture splint, night splint or a foot drop splint.A static or dynamic positioning ankle-foot orthosis (L4396, L4397) is a prefabricated ankle-foot orthosis which has all of the following characteristics:Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45; and,Applies a dorsiflexion force to the ankle; and,Used by a beneficiary who is minimally ambulatory, or non-ambulatory; and,Has a soft interface.A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of the following characteristics:Designed to maintain the foot at a fixed position of 0 (i.e., perpendicular to the lower leg); and,Not designed to accommodate an ankle with a plantar flexion contracture; and,Used by a beneficiary who is non-ambulatory; and,Has a soft interface.SHOE INSERTSFoot orthoses are shoe inserts that do not extend above the ankle. Shoes, inserts, and shoe modifications that are integral components of a leg brace are referred to as orthopedic footwear (ORF). These shoes, inserts, and shoe modifications are only covered if they are an integral part of a covered leg brace that is described by HCPCS code L1900, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2050, L2060, L2080, or L2090. In addition to being an integral component of the covered leg brace, these products must also be medically necessary for the proper functioning of the leg brace. When billing for ORF, the leg brace and ORF must be billed by the same supplier (refer to the Orthopedic Footwear policy for more information).Multiple density foot orthotics that are provisioned in the treatment of a beneficiarys diabetes-related condition(s), must not be billed using L-codes but rather must be billed using A-codes. The A-codes for billing of such foot orthotics are A5512, A5513, and A5514 (code A5514 effective for DOS on or after 01/01/2019) (refer to the Therapeutic Shoes for Persons with Diabetes policy for more information).CONCENTRIC TORSION JOINTSAll 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 must be coded as durable medical equipment using code E1810 (DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). If a concentric adjustable torsion style mechanism in the knee joint is used solely to provide an assistive function for joint extension, it must be coded as L2999 (See Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD).All 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 must be coded as durable medical equipment using code E1815 (DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). If a concentric adjustable torsion style mechanism in the ankle joint is used solely to provide an assistive function for joint plantar or dorsiflexion, it must be coded as L2999 (See Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD).Claims for devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint and that are being used to treat any condition other than an assistive function to joint extension motion are not covered under the braces benefit and will be denied as incorrect coding when billed using code L2999 (See Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD).WALKING BOOTSPrefabricated walking boots are coded using codes L4360, L4361, L4386 or L4387.These codes describe complete products.Claims for add-on codes used with walking boots coded L4360, L4361, L4386 or L4387 will be denied as unbundling.Certain products may have both covered and non-covered uses, as defined by the braces benefit category, and must be coded based on the beneficiarys condition. For example, when used as a brace for the treatment of an orthopedic condition, walking boots are coded L4360, L4361, L4386, L4387 and L4631. However, walking boots must be coded A9283 when used solely for the prevention or treatment of a lower extremity ulcer or pressure reduction.OTHER DEVICES