L1952?

As of April 1, 2025, CMS issues a new code L1952 which is an off the shelf version of L1951.

L1951 Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment

L1952 Spiral AFO Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, ​o​ff the shelf

It is important to note that both codes require PDAC validation.

​PDAC has required L1951 devices to be validated for quite some time and most had dual validations of L1951 and L2999 (miscellaneous). This is because the proper coding is dependent on what is done at the time of delivery not at the time of manufacturing. Thus if a provider sends assembly or modification orders to the factory and all the provider did was to adjust a strap or do something a lay person could do to fit the brace, the miscellaneous code (L2999) was the only proper code to submit.

This because, what the manufacturer or distributor does to the brace at the factory based on the prescriber's orders,  does not count as "at the time of delivery". This would not qualify the device as custom fitted.

ONLY what the provider does as the time of delivery, which is beyond minimal self adjustment distinguishes a brace as custom fitted or off the shelf. This must be documented at the time of delivery. Such measures including, trimming, grinding, heating, modifying padding, etc. are beyond minimal self adjustment. Adding or subtracting strapping will normal not qualify as beyond minimal self adjustment.

This new code was developed in response to a great deal of 

providers submitting claims requiring manual processing for L2999. In response, HCPCS and PDAC approved L1952.

Thus as of April 1, 2025, any L1951 brace previoulsy validated as L1951/L2999 now have been dual coded as both L1951 and L1952. 

Also note that L1951 requires prior approval by the DME MAC, whereas L1952 does not require prior approval.

The DMEPOS fee schedule for both L1951 and L1952 is the same and is state based (where the patient lives). The DME fee schedule has been updated as of April 1, 2025. The annual or first quarter fee schedule will not have L1952. To obtain the full fee schedule for DMEPOS you can go to either your DME MAC home page, the PDAC or CMS website.

Most important, in the past, the DME MAC and other agencies involved in recoupment such as the RAC have been overwhelmingly succesfull at clawbacks for custom fitted bracing. This due the lack of documentation by providers illustrating what was done to "custom fit" the device and their qualifications in doing so.

You can be sure, that L1951 will also be added to the paired list of codes which will receive extra scrutiny from the bean counters.