Knee orthoses or braces are an important element in pain management billing. They are a part of a treatment protocol that may include surgery, drugs and physical therapy. Physicians prescribe several types of knee orthoses (sleeve, patello-femoral, hinged or unicompartmental offloading braces) to support healing for diseases, injuries and inflammation that affect the knee joint. Conditions that may make patients eligible for knee orthoses include knee flexion contracture, knee extension contracture, weakness or deformity of the knee and recent injury and/post-surgical recovery and rehabilitation of the knee.
The Centers for Medicare and Medicaid (CMS) recently sent physicians a notification warning that knee orthoses have constantly been one of the highest sources of errors in medical reviews performed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Comprehensive Error Rate Testing (CERT) contractor. Meeting payer documentation and reporting requirements is the key to proper reimbursement from Medicare and private insurance companies.
Types of Knee Braces and their Functions
The most common types of knee orthoses are:
- Patellofemoral – help the kneecap move smoothly over the joint
- Rehabilitative – limit movement after an injury or surgery, so that damaged tissues heal properly
- Functional – provide support to the injured knee
Criteria for Claim Reimbursement
CMS covers only services provided to patients that are reasonable and medically necessary and that meet the criteria for coverage of knee orthoses. According the Medicare Benefit Policy Manual, braces are “rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”
Knee Orthotics – Know the Definitions to Ensure Correct Coding
Knee orthotics may be custom fabricated or prefabricated (off-the-shelf).
Custom fitted orthotics must meet two requirements. Classification as custom fitted requires:
- Substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment
- This fitting at delivery does require the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.
Off-the-shelf (OTS) orthotics:
- Are prefabricated.
- They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
- OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual.
- This fitting does not require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthoses to fit the item to the individual beneficiary.
CGS Requirements for Knee Orthoses Claims
A recent AAPC article sums up CGS requirements for knee orthoses claims as follows:
- The othoses must be rigid enough to permit demobilization and support the body part.
- Medical necessity is specific to the body part for each type of orthosis
- While custom fabricated knee orthoses and the same type of prefabricated knee orthosis have the same basic coverage criteria, the documentation in the records should justify the medical necessity of a custom fabricated device instead of a prefabricated orthosis. The reasons could include:
- Deformity of the leg or knee
- Size of the patient’s thigh and calf
- Minimal muscle mass upon which to suspend the orthosis
Knee Orthoses Codes
CMS requires that the knee orthosis must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Claims submitted using following knee orthoses codes should meet Medicare documentation requirements:
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
Documentation Essentials
- Ordering physicians need to document the medical necessity for durable medical equipment, prosthetics, orthotics and supplies, including the patient’s functional capabilities, type of and if a custom brace is needed.
- Chart notes should be included reflecting the need for the care (e.g., treatment plan, history and physical, operative report) from the patient’s medical records (located at the physician’s office, hospital, or nursing home).
- The ordering physician should ensure that the patient’s medical records contains the following information:
- History of the Injury, Illness, or Condition
- Description of nature and extent of functional limitations on a typical day
- Past experience with orthosis/brace and other failed treatments
- Recent physical examination that is relevant to functional deficits
- Document whether the patient meets the criteria for custom fabricated, rather than prefabricated (if pertinent)
- Recommendation for the type of knee orthosis and/or components
- The practitioner should ensure that the dispensing order complies with state prescribing and/or other applicable laws.
Proper documentation will allow medical billing and coding service providers to assign the right codes and ensure accurate submission of claims for knee orthotics.
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