HCPCS L1970: Ankle-Foot Orthosis, plastic with ankle joint

Obtain a list of documentation and billing requirements needed to properly use and bill for HCPCS L1970 from our short guide.

Use Code

## **What is HCPCS code L1970?** HCPCS code L1970 is a code with a description: Ankle foot orthosis (AFO), plastic with ankle joint, custom-fabricated. It denotes a custom-fabricated ankle–foot orthosis (AFO) constructed from plastic and incorporating an articulated ankle joint. This ankle plastic orthosis is tailored to the individual patient’s anatomy using molds or casts taken from the lower extremity. The joint allows controlled motion—typically dorsiflexion and plantarflexion—enhancing functional mobility while maintaining stability. Indications include gait abnormalities, neuromuscular conditions (e.g., foot drop), deformity correction, or mobility limitations requiring dynamic control through an ankle mechanism.

## **HCPCS code L1970 documentation requirements** To ensure proper billing and coverage, particularly for Medicare, thorough documentation is essential. Key requirements should be included in the patient's medical records: - **Standard Written Order (SWO)**: This must be obtained before the device is delivered. It should include the patient's name, the order date, a clear description of the item (the HCPCS code or a narrative description), the quantity, the treating practitioner's name, and their signature. - **Medical necessity**: The patient's medical record must clearly justify the need for a custom-fabricated AFO over a less expensive, prefabricated, or off-the-shelf option. This is a critical point for code L1970. The documentation should state that the patient could not be fit with a prefabricated orthosis due to their condition. Specific reasons could include: the condition is permanent or expected to be long-standing (more than six months); there is a need to control the knee, ankle, or foot in more than one plane; the patient has a neurological, circulatory, or orthopedic status that necessitates a custom-fabricated device to prevent tissue injury. - **Face-to-face encounter**: A face-to-face encounter between the patient and the prescribing practitioner is required before the delivery of the L1970 orthosis. - **Proof of delivery**: The supplier must maintain documentation, such as a signed delivery invoice, that confirms the patient received the item.

## **L1970 billing requirements** Billing for L1970 is subject to specific guidelines to ensure compliance and avoid denials. - **Bundled services**: The reimbursement for L1970 includes the cost of the device, as well as the evaluation, measurements, casting, fabrication, and fitting/adjustments. These services should not be billed separately. - **Modifiers**: Appropriate modifiers, such as -LT for the left side and -RT for the right side, should be used to specify the limb on which the orthosis was used. Modifiers like -KX may be necessary to indicate that specific coverage criteria have been met. - **Prior authorization**: While not always required, some payers and Medicare programs may require prior authorization for the proper use of L1970. It is crucial to check with the specific payer's policies before providing the device. - **Replacement**: The reasonable useful lifetime (RUL) of an AFO for Medicare is generally considered to be five years. A new device will typically not be covered before the RUL is met unless the original device is lost, stolen, or irreparably damaged, or there's a significant change in the patient's medical condition warranting a replacement. Do note that this code typically corresponds to moderate-complexity billing events, reflecting increased fabrication complexity and clinical decision-making.

## **Other relevant codes** - **L1960**: Ankle-Foot Orthosis, posterior solid ankle, plastic, custom-fabricated. This is a solid, non-articulating AFO, unlike the L1970 which has an ankle joint - **L1940**: Ankle foot orthosis (AFO), plastic or other material, custom-fabricated - **L1971**: Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, includes fitting and adjustment - **L2820**: Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

Frequently asked questions

Use L1970 when the AFO is custom-fabricated (made from a mold or model) and includes an articulated ankle joint. If it's prefabricated, even with fitting, use L1971 for proper billing.

It's possible to bill L1970 with certain add-on codes (e.g., L2820) for additional components. However, services like the initial evaluation, casting, and fitting are bundled into the L1970 code and cannot be billed separately.

No prior authorization is required under CMS’s master list, but a face-to-face encounter and written order are mandatory before delivery. Some Medicare Administrative Contractors (MACs) may place L1970 under review or require prior authorization through specific programs. Many state Medicaid programs and commercial insurers do require prior authorization, so always confirm requirements with the payer before fabrication and delivery.