Wiki HCPCS L1851 - M17.11 supports alone for a Medicare JC audit?

nolanspade

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The LCD and article are stumping me in their verbiage for the medical necessity of the knee brace L1851. The LCD L33318 states:
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-related Policy Article.
When I checked the group 4 ICD-10 codes, M17.11 (unilateral primary osteoarthritis, right knee) is listed in the LCD-related policy article, A52465.

However, L33318 also states
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.
Does that mean that a history of M17.11, as confirmed by radiology, does not support medical necessity of the brace per the above LCD? Do both criteria need to be met?

Thanks for your help!!!
 
Hello Nolan,
I bill at a DME manufacturer and in our experience, yes, both dx's need to be met or the claim will be denied. The provider has to document joint laxity testing via what you listed above.
I just posted a separate question regarding modifiers in this same code set. I would love your feedback on that! Thanks! Cindy
 
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