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Linda Collins Blogger

Audit Results for Ankle Foot Orthosis

Posted by Linda Collins | April 11, 2016

​Noridian, Medicare Jurisdiction D, announced results of a pre-payment audit for Ankle-Foot Orthosis (AFO) billed with HCPCS codes L1960, L1970 and L4360. The overall claim potential improper payment rate ranged from 75-98%.

The reasons for denial include:

  • Insufficient documentation on modifications for custom fit braces
  • Invalid or missing Proof of Delivery
  • Medical necessity of custom item not detailed in the medical records

L1960 and L1970 describe custom fabricated AFOs.

L4360 is a custom fit AFO.

What does this mean for you?

First, understand the difference between an off the shelf, custom fit and custom orthosis. An off the shelf orthosis is prefabricated and requires only minimal self-adjustment at the time of fitting. The custom fit codes describe an orthosis that is prefabricated and requires substantial modifications to fit the patient. A custom orthosis is one that is fabricated to fit the specific patient.

The substantial modifications required on a custom fit brace must be documented in great detail and include and explanation of why the modifications are needed. The physician's notes do not need to state "custom fit", but the fitters notes need to be specific.

Secondly, be familiar with the documentation requirements for custom braces. According to the Local Coverage Determination for AFOs/KAFOs, the treating physician's medical records must have detailed information regarding the need for a custom fabricated brace. Reasons for a custom brace may include:

  • The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
  • There is a need to control the knee, ankle or foot in more than one plane; or,
  • The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
  • The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

Information in the physician's records must be corroborated in the Orthotist's records.

You may read the full audit report here. More information about the LCD and Policy Article for AFOs/KAFOs can be found here. Össur also offers reimbursement fact sheets, which are available for download under the "Reimbursement Resources" section on this page. 

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