Code Knee Orthoses Right to Get Braces Paid

Knee orthoses are one of the highest sources of errors, a letter from CGS to providers warns, and the Medicare Administrative Contractor’s (MAC) wants providers to be more careful with documentation and reporting.

How Do We Get Paid?

The Centers for Medicare & Medicaid Services (CMS) requires medical necessity for the diagnosis or treatment of the body part. According to Social Security Act, orthoses must be a rigid or semi-rigid device,  be used to supporting a weak or deformed body member, or eliminating motion in a diseased or injured body part to recognize the Medicare Braces Benefit. That means to receive reimbursement, the item must be rigid enough to permit demobilization and support the body part. For each type of orthosis, medical necessity is specific to that body part.

CGS also advises providers that while custom fabricated knee orthoses have the same basic coverage criteria as teh same type of prefabricated knee orthosis, there must be documentation in the records medically describing why the patient needs a custom fabricated device instead of a prefabricated orthosis. Examples of this include these reasons:

• Deformity of the leg or knee
• Size of the patient’s thigh and calf
• Minimal muscle mass upon which to suspend the orthosis

This is important for the following codes:

L1810    Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1812    Knee orthosis, elastic with joints, prefabricated, off-the-shelf

L1820    Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment

L1830    Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf

L1831    Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

L1832    Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1833    Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf

L1834    Knee orthosis, without knee joint, rigid, custom fabricated

L1836    Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf

L1840    Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1843    Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1844    Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

L1845    Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1846    Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

L1847    Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1848    Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf

L1850    Knee orthosis, swedish type, prefabricated, off-the-shelf

L1851    Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

L1852    Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

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Brad Ericson

Director of Publishing at AAPC

Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 11 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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