LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2013-08 Updated LCD L11527, Part 2

KYDEX-PRO

STRONGER

SAFER

LEEDerGroup.com

L2037
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED
L2038
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE, MULTI-AXIS
ANKLE, CUSTOM FABRICATED
L2106
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC
TYPE CASTING MATERIAL, CUSTOM-FABRICATED
L2108
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOMFABRICATED
L2112
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
L2114
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2116
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
L2126
KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS,
THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED
L2128
KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOMFABRICATED
L2132
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
L2134
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
L2136
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
L2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE JOINTS
L2182 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT
L2184 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT
L2186
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT, LERMAN
TYPE
L2188 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIM
L2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT
L2192
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH FLANGE, AND
PELVIC BELT
L2200 ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT
L2210 ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT
L2220 ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT
L2230 ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT
L2232
ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT
ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2240 ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT
L2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT
L2260 ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)
L2265 ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP
L2270
ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION (‘T’) STRAP, PADDED/LINED OR
MALLEOLUS PAD
L2275
ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION,
PADDED/LINED
L2280 ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT
L2300
ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED,
ADJUSTABLE
L2310 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT
L2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2330
ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED
ORTHOSIS ONLY
L2335 ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND
L2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL
L2350
ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL,
(USED FORPTB’ ‘AFOORTHOSES)
L2360 ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK
L2370 ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM
L2375 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP
L2380 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT
L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT
L2387
ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE
FOOT ORTHOSIS, EACH JOINT
L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT
L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT
L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE
L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACH
L2415
ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY
MATERIAL, EACH JOINT
L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINT
L2430
ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH
JOINT
L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING
L2500 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING
L2510
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO
PATIENT MODEL
L2520 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTED
L2525
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM
MOLDED TO PATIENT MODEL
L2526
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L
BRIM, CUSTOM FITTED
L2530 ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED
L2540 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL
L2550 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFF
L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR
L2755
ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID
LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2760
ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR LINEAL
ADJUSTMENT FOR GROWTH)
L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR
L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR
L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH
L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP
L2800
ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL,
FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY
L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD
L2820
ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE
SECTION
L2830
ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE
SECTION
L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACH
L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACH
L2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED
L4002 REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE
L4010 REPLACE TRILATERAL SOCKET BRIM
L4020 REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL
L4030 REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED
L4040 REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4045 REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4050 REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4055 REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4060 REPLACE HIGH ROLL CUFF
L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO
L4080 REPLACE METAL BANDS KAFO, PROXIMAL THIGH
L4090 REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH
L4100 REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH
L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH
L4130 REPLACE PRETIBIAL SHELL
L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES
L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS
L4350
ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4360
WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4386
WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4392 REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO
L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT
L4396
STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4398
FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4631
ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED
ICD-9 Codes that Support Medical Necessity
The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.
For HCPCS codes L4392 and L4396:
718.47 CONTRACTURE OF ANKLE AND FOOT JOINT
728.71 PLANTAR FASCIAL FIBROMATOSIS
L4631
713.5 ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS

  • Diagnoses that Support Medical Necessity
    For the specific HCPCS codes indicated above, refer to previous section. For all other HCPCS codes, diagnoses are not specified.
    ICD-9 Codes that DO NOT Support Medical Necessity
    For the specific HCPCS code indicated above, all ICD-9 codes that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.
    ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
    Diagnoses that DO NOT Support Medical Necessity
    For the specific HCPCS code indicated above, all diagnoses that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.

General Information
  • Documentation Requirements
    Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the beneficiary’s medical records will reflect the need for the care provided. The beneficiary’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.
  • PRESCRIPTION (ORDER) REQUIREMENTS GENERAL (PIM 5.2.1)
    All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed that do not meet these prescription requirements and those below must be submitted
    with an EY modifier added to each affected HCPCS code.
  • DISPENSING ORDERS (PIM 5.2.2)
    Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:
    • Description of the item
    • Beneficiary’s name
    • Prescribing Physician’s name
    • Date of the order and the start date, if the start date is different from the date of the order
    • Physician signature (if a written order) or supplier signature (if verbal order)
    For the “Date of the order” described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders). Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.
    The dispensing order must be available upon request. For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim.
  • DETAILED WRITTEN ORDERS (PIM 5.2.3)
    A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:
    • Beneficiary’s name
    • Physician’s name
    • Date of the order and the start date, if start date is different from the date of the order
    • Detailed description of the item(s) (see below for specific requirements for selected items)
    • Physician signature and signature date
    The order must list the unique features of the base code that is billed plus every addition that will be billed on a separate claim line. For the “Date of the order” described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders). The detailed description in the written order may be either a narrative description or a brand name/model number. Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.
    The DWO must be available upon request. A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.
  • MEDICAL RECORD INFORMATION GENERAL (PIM 5.7 -5.9)
    The Indications and Limitations of Coverage and/or Medical Necessitysection of this LCD contains numerous reasonable and necessary (R&N) requirements. The Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article contains numerous non-reasonable and necessary, benefit category and statutory requirements that must be met in order for payment to be justified. Suppliers are reminded that:
    • Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.
    • Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information in the medical record. Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician’s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is
    reasonable and necessary. The supplier must include on the claim the ICD-9 diagnosis code for the underlying condition for a static or dynamic positioning AFO (L4396) or replacement interface material (L4392). For a custom-fabricated orthosis, there must be documentation in the supplier’s records to support the medical necessity of that type device rather than a prefabricated orthosis. This information must be available upon
    request.