Ankle-Foot Orthosis (AFO) Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for AFO HCPCS codes L1900-L1990, L2000, L2005, L2010-L2136, L4350-L4387, L4396-L4397, L4631 reviewed July 1 – September 30, 2024. The error rate for this quarter is 30.42%. The top 10 reasons for claim denials are as follows:
| Rank | Reason | Percent |
|---|---|---|
| 1. | The HCPCS procedure code on the claim is not correct for the items billed. | 27.44% |
| 2. | The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. | 22.74% |
| 3. | No medical record documentation was received. | 10.83% |
| 4. | The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. | 9.75% |
| 5. | The documentation does not have a valid order. | 9.39% |
| 6. | The claim was submitted with an incorrect modifier. | 2.89% |
| 7. | Documentation provided in the supplier’s records and the treating practitioner’s medical record do not support the medical necessity of a custom fabricated orthosis rather than a prefabricated orthosis. | 2.53% |
| 8. | The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. | 2.53% |
| 9. | The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. | 2.17% |
| 10. | The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. | 2.17% |
*The total percentage will be greater than 100% because some claims denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Ankle-Foot/Knee-Ankle-Foot Orthosis Documentation Checklist

- Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686)

- Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Article (A52457)

- Orthotics and Prosthetics Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

- Supplier Manual Chapter 3 – Supplier Documentation

Updated: November 5, 2024

