A common AFO L1951: Ankle foot orthosis (AFO), spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment has been in the news for some time.
Hopefully many of you have found this slim and easy to fit device to be particularly useful for patients with drop feet. To secure reimbursement and avoid recoupments, the last part of its narrative stipulates the need for the provider to do something in the office at the time of delivery. That is, you must document at the time of delivery a modification beyond minimal self-adjustment that might have otherwise been performed by a layperson. That is your chart must illustrate what advanced skills you used to modify the device. Some examples include grinding, heating, molding, grinding or adding or removing materials.
Second, you must document that you possess the requisite advanced skills as a physician (MD/DO/DPM), orthotist or pedorthist to perform such modifications. Failing to document the performance of these measures may result in money being claw backed upon audit.
The larger issue is that of prior authorization requirements, which went into effect sometime ago. This can be largely accomplished by using the provider portals of Noridian (JA or JD) or CGS ( JB or JC).
The seamless process using the provider portals requires entering typical patient biographical information and providing the HCPCS and ICD10 codes and patient chart information supporting medical necessity. At a recent discussion with the DME MACs they touted that prior authorizations for L1951 are provided in excess of 85% typically within 5 days of submission. Providers can track the process through the portal.
Once the prior authorization is processed, a unique ID for that authorization will be provided and must be placed into the appropriate sections of the paper or electronic claim forms.
Once received, this unique identification follows the patient and can be used by any provider who dispenses the device. It is important to remember that your office may perform all the work to obtain the prior authorization, but the patient is free to select another provider. That is the patient can obtain authorization from Medicare and use another provider. The need for proper communication with the patient cannot be underestimated.
Our next installment will describe a new HCPCS code L1952 (effective April 2025) which is an off-the-shelf version of L1951 as well as existing code L1932 and another new code L1933.
