Six More Codes, Eight Weeks to Prep

If your team finally got comfortable with the prior authorization changes that landed in April, I hate to be the one to tell you but on July 29, CMS announced that six more orthotic codes are moving onto the Required Prior Authorization List, and nine are being added to the Required Face-to-Face Encounter and Written Order Prior to Delivery list. All of it applies to dates of service on or after October 28, 2026. 

Count the weeks. There are eight of them. 

What Is Changing 

Four codes go nationwide on October 28 with no phase-in and no grace period: 

• L0456 and L0457 — flexible TLSOs, prefabricated 

• L0486 — custom fabricated triplanar TLSO 

• L1833 — off-the-shelf knee orthosis with adjustable joints 

Two upper limb codes, L3761 (elbow orthosis) and L3916 (wrist-hand orthosis), roll out by geography instead: 

• October 28, 2026: California, Florida, Michigan, New York 

• January 26, 2027: Arizona, Georgia, Illinois, Massachusetts, Ohio, Oregon, Pennsylvania, Texas 

• April 26, 2027: everyone else 

The face-to-face and written order list picks up those same six codes plus three off-the-shelf AFOs: L1906, L1933, and L1952. 

When this settles, our profession will have 27 codes requiring prior authorization and 32 requiring a documented face-to-face encounter and a written order before delivery. If you fit spinal orthoses or off-the-shelf knee braces in any real volume, this reaches beyond the billing team and into your daily schedule. 

One wrinkle worth catching: L1833 has been through this before. It required prior authorization until August 2024, when CMS took it off the list. Now it is back. If anyone on your billing team was here for the first round, or if the old workflow notes are sitting in a folder somewhere, go find them. 

The ST Modifier Is Not the Escape Hatch 

AOPA reports that the six new orthotic codes are expected to be eligible for the ST modifier, which flags an emergent need where waiting on prior authorization would risk further injury or harm to the patient. Claims carrying an ST modifier are exempt from the prior authorization requirement. 

But read the rest of it. Those claims draw prepayment medical review 50% of the time. That is a coin flip on each one you submit. The modifier is there for the patient who truly cannot wait five to seven days, and your record needs to show why. Used as a convenience, it will cost you more time than the prior auth would have. 

Dates for the Whiteboard 

• Now through mid-October: get the new codes flagged in your system and your staff trained on which ones changed. 

• On or around October 19: the DME MACs are expected to begin accepting prior authorization requests for the four nationwide codes. Standard review runs up to seven calendar days, so that nine-day head start is not as generous as it sounds. 

• October 28: prior authorization and the face-to-face and written order requirements take effect, phase one states only for the two upper limb codes. 

• January 26 and April 26, 2027: the remaining phases for L3761 and L3916. 

Four Things Worth Doing Before October 

Run your numbers first. Pull the last twelve months of claims on L0456, L0457, L0486, L1833, L1906, L1933, L1952, and the two upper limb codes if you are in a phase one state. Volume tells you where your training time belongs. If you deliver two of these a year, this is a checklist item. If you deliver forty, it is a workflow project. (Your OPIE Business Intelligence dashboards will get you this in a few minutes.)  

Check the face-to-face documentation, not just the box. The encounter has to occur within six months before the order is written. The findings belong in the medical record, not only in a letter of medical necessity. And the written order needs all six elements in place before delivery: patient name or Medicare Beneficiary Identifier, order date, a general description of the item, quantity, the treating practitioner's name or NPI, and that practitioner's signature. Auditors read these requirements literally, and so should you. 

Tell your referral sources now, not in November. You can also use the OPIE BI to see which referrers are sending those codes to you most frequently. Use that information to prioritize your outreach. A physician's office that does not know these codes now require a documented encounter and a compliant order will hand you an incomplete file. That delay lands on your schedule and in your patient's wait time, not theirs. A one-page sheet for your top referrers costs you an afternoon and saves you a quarter of phone calls. 

Know what is pending. Whether it is a dashboard or a whiteboard, somebody in your practice should be able to answer two questions without going chart by chart: what is waiting on authorization right now, and how long has it been sitting there? Requests that quietly age past the seven-day window are how a delivery date slips and nobody notices until the patient calls. 

Closing Thought 

None of this is new work. It is the same discipline you built around the codes that changed in April, applied to a different set of L-codes. CMS has said it will publish subregulatory guidance on implementation as the date gets closer, so keep an eye on your MAC bulletins over the next few weeks and follow your jurisdiction's guidance over anything you read here, including this blog. 

The practices that have a hard October will not be the ones who never heard about the change. They will be the ones who heard about it in August and meant to get to it.