Part 2 of L1951 and L1952
Effective April 1, 2025, CMS has introduced several new HCPCS codes affecting lower extremity providers. The first example this article will cover is L1952:
Ankle foot orthosis, spiral (institute of rehabilitative medicine type), plastic or other material, prefabricated, off-the-shelf.
Hopefully this code looks somewhat familiar to you as there is an existing code L1951:
Ankle foot orthosis (AFO), spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment.
However, L1951 has also had a slight narrative change to explain the requirements of fitting and adjustment to:
ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE
Also added in April 2025, HCPCS code L1933 defined as ANKLE FOOT ORTHOSIS, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, OFF-THE-SHELF. This is the off-the-shelf version of L1932, the lower code of this paired set. This latter or lower code of the paired set is the same definition other than the fact that it like L1951 requires the same “custom fitting” narrative and thus L1932 code has also been changed to:
ANKLE FOOT ORTHOSIS, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE
The distinctive difference between these two (of the newest paired sets), is that the lower (and older existing) code requires custom fitting and now is specifically spelled out. That is the lower code of these pairs requires heating, grinding and bending (as examples) which must be performed by someone with the expertise to perform such measures. Both should be documented!
The newly introduced codes are off-the-shelf not requiring custom fitting.
As with other coded pairs, there is no fee schedule differential between these two codes.
So why did CMS choose to introduce this new code and how does this affect you?
Because there was no off-the-shelf version of these devices, providers were forced to submit claims with the L2999 (miscellaneous lower extremity orthosis) or face claw backs on audit when custom fitting was not documented. CMS introduced the new code (L1952 and L1933) largely to reduce the associated costs of their manually processing claims billed as L2999.
Additionally, L1951 as discussed in Part 1 of this installment, requires pre-authorization, whereas L1952, L1932 nor L1933 do not require pre-authorization. When contemplating providing an L1951/LI952, if you are not sure if you may perform custom fitting, then it is wise to obtain prior authorization for L1951.
It is important to remember that L1951/L1952 and now L1932/L1933 are not the only paired codes affecting lower extremity providers. Other examples include familiar code sets such as L4360/L4361, L4386/L4387, L4396/L4397.
The DME MAC have been auditing these paired code sets, for some time. They have been highly successful in recouping and clawing back money for the custom fit, lower code of the paired set. It is best that if you do not perform custom fitting at the time of delivery or do not do document it, always select the higher code of the paired set. There is no financial incentive for billing the custom fitted code and successful audit defense is far easier with the off-the shelf code. Additionally, the products within the code sets are the same and may have dual validation from the PDAC.
Remember it is what you the provider did at the time of delivery, not what the central fabrication lab may have done to customize an orthotic, that must be documented to support the lower (custom fitted) code.
