New AFO PA language
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Local Carrier Determinations (LCD) for all products and services provided by medical professionals, must go through arduous review process in accordance with the 21st Century Cures Act. To avoid this lengthy and expensive process, all Medicare Contractors rely on Policy Articles (PA), which do not require this arduous approval process. The PA are attached to the LCD and provide coding, both procedural (CPT or HCPCS) and diagnostic supporting and supplementing the LCD. Medicare Administrative Contractors release minor language revision for multiple PA on a regular basis. The advantage of having PA which can be easily incorporated into policy, is that it allows for more efficient updating of policy. The drawback however is that updates to the PA do not allow for a formal comment period, mandated by LCD revisions.
Recently, a rather innocent language change occurred within the AFO PA that may require some tweaking of your documentation. Until recently the PA stated:
“Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary”.
As of April 1, 2026, the AFO PA has been changed to include this revision (note: underlined and italicized):
“Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of why the modifications are necessary and what modifications were performed at the time of fitting the orthosis to the beneficiary.,"”One might think this is a minor revision. Further analysis brings this PA sentence to be consistent with the language of the LCD. The AFO LCD specifically states the following:
- “The medical device must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, “ and
- The custom fabricated AFO…. codes used for ambulation must have the potential to benefit functionally.
This minor modification in the PA updates its requirements to match the LCD. In everyday parlance, this means your chart must state how any product or device has the potential to improve the patient’s function. Using a custom solid AFO for a patient post CVA with a complete drop foot as an example, the chart note must now reflect what the expected needs are for the patient. Simply stating that the patient needs a solid AFO to correct the drop foot may have been sufficient prior to 4/1/26, but under the current PA this no longer may be sufficient.
Currently your documentation should include: The patient has a drop foot which causes their toes to drag and creates significant instability. The prescribed solid AFO will reduce foot drag and correct the drop foot, allowing for toe and foot clearance thereby correcting the instability. Having performed peer reviews for two or more decades, including a reference to recent peer review article (e.g. Commonly used Types and Recent Development of AFO: A Narrative Review Healthcare (Basel. 2021 Aug 13;9(8):1046. doi: 10.3390/healthcare9081046 is highly suggested.
Others may choose to quote the article.” A solid AFO has been shown to be quite effective in preventing the foot from being dragged, provides a clearance between the foot and the ground in the swinging phase of gait, and maintains a stable posture by allowing heel contact with the ground during the stance phase.”
This update also impacts modification made to custom fabricated modifications or custom fitted AFO at the time of delivery. Chart documentation now needs to reference issues such as “The patients’ atrophic lower limb lends itself to ulceration and the soft interface will increase comfort compliance and reduce the likelihood of ulceration. Other examples include, the patient’s partial drop foot requires a dorsiflex assist hinge to promote toe clearance but is not severe enough to require placement into a solid AFO. At the time of delivery the hinge was tightened to allow adjust for adequate dorsiflexion force to obtain adequate toe clearance.
This update in the PA is not limited to AFO or DME policy and is a sign of what has arrived to much of medicine. Incorporating what you are doing is not enough. Now you need to defend what care you are providing with some why that medical care is required. Providing some quotes or references of unbiased opinion supporting the why’s of your treatment consistent with third party policy, may also be advantageous.
Performing an internet search for peer reviewed sources can easily be accomplished in a few seconds. In fact, many LCD provide accompanying and supporting references in the bibliography of their policies. Often this is a great place to start to build your own library of reference materials. As the article cited above, a few minutes of research may often yield a single article you can reference in support of treatment plans, for many patients.
KevinRoot will continue to build a library of these resources to assist you with complying with these regulations to ease your additional documentation burdens.
