LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2011-07 Local Coverage Determination (LCD) for Knee Orthoses L27263

Local Coverage Determination (LCD) for Knee Orthoses
(L27263)
Contractor Information
Contractor Name
NHIC, Corp.
Contractor Number
16003
Contractor Type
DME MAC
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LCD Information
Document Information
LCD ID Number
L27263
LCD Title
Knee Orthoses
Contractor’s Determination Number
KO
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright
2010 American Medical Association (or such other date of
publication of CPT). All Rights Reserved. Applicable
FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature,
descriptors and other data contained therein) is copyright
by the American Dental Association. © 2002, 2004
American Dental Association. All rights reserved.
Applicable FARS/DFARS apply.
Primary Geographic Jurisdiction
Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York – Entire State
Pennsylvania
Rhode Island
Vermont
Oversight Region
Region I
DME Region LCD Covers
Jurisdiction A
Original Determination Effective Date
For services performed on or after 07/01/2008
Original Determination Ending Date
Revision Effective Date
For services performed on or after 07/01/2011
Revision Ending Date
CMS National Coverage Policy
None
Indications and Limitations of Coverage and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body
member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for “reasonable and necessary”, based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.
For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item
will be denied as not reasonable and necessary.
PREFABRICATED KNEE ORTHOSES (L1810, L1820, L1830 – L1832, L1836, L1843, L1845, L1847, L1850):
A knee flexion contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by passive range of motion. (0 degrees knee extension is when the femur and tibia are in alignment in a horizontal plane). A knee extension contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 80 degrees flexion or greater by passive range of motion. A contracture is distinguished from the temporary loss of range of motion of a joint following injury, surgery, casting, or other immobilization. A knee orthosis with joints (L1810) or knee orthosis with condylar pads and joints with or without patellar control (L1820) are covered for ambulatory patients who have weakness or deformity of the knee and require stabilization. If an L1810 or L1820 is provided but the criteria above are not met, the orthosis will be denied as not reasonable and necessary. A knee orthosis with a locking knee joint (L1831) or a rigid knee orthosis (L1836) is covered for patients with flexion or extension contractures of the knee (ICD-9 diagnosis code 718.46) with movement on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture). If an L1831 or L1836 orthosis is provided but the criterion above is not met, the orthosis will be denied as not reasonable and necessary.
There is no proven clinical benefit to the inflatable air bladder incorporated into the design of code L1847; therefore, claims for code L1847 will be denied as not reasonable and necessary. A knee immobilizer without joints (L1830) or a knee orthosis with adjustable knee joints (L1832) is covered if the patient has had recent injury to or a surgical procedure on the knee(s) and has one of the following diagnoses:
Diagnosis ICD-9
Rheumatoidarthritis 714.0 –714.4
Osteoarthritis 715.16,715.26,715.36,715.96
Meniscal cartilage derangement 717.0 –717.5
Chondromalacia of patella 717.7
Knee ligamentous disruption 717.81 – 717.9
Rupture of tendon, nontraumatic – quadriceps tendon 727.65
Pathologic fracture of femur 733.15
Pathologic fracture of tibia or fibula 733.16
Aseptic necrosis of tibia or fibula 733.49
Stress fracture of tibia or fibula 733.93
Congenital deformity of knee 755.64
Fracture of femur – lower end 821.20 – 821.39
Fracture of patella 822.0, 822.1
Fracture of tibia and/or fibula – upper end 823.00 – 823.42
Dislocation of knee 836.0 – 836.69
Sprains and strains of knee 844.0 – 844.2, 844.8
Failed total knee arthroplasty 996.40 – 996.49, 996.66, 996.77, V43.65
An L1832 knee orthosis is also covered for a patient who is ambulatory and has knee instability due to a condition specified in one of the following diagnoses:
Any diagnosis listed above; or Diagnosis ICD-9
Multiple sclerosis 340
Hemiplegia, unspecified; dominant side; nondominant side 342.90, 342.91, 342.92
Infantile cerebral palsy, unspecified 343.9
Paraplegia of both lower limbs 344.1
Mononeuritis of lower limb, unspecified 355.0, 355.2
A knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845) is covered for a patient who is ambulatory and has knee instability due to a condition specified by one of the diagnoses for L1832 listed above.
A knee orthosis, Swedish type, prefabricated (L1850) is covered for a patient who is ambulatory and has knee instability due to genu recurvatum – hyperextended knee (736.5).
For codes L1832, L1843, L1845 and L1850, 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, L1843, L1845, or L1850 will be denied as not reasonable and necessary when the patient 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.
“Addition” codes are grouped into four (4) categories in relation to knee orthosis base codes.
• Eligible for separate payment
• Not reasonable and necessary
• Not separately payable
• Incompatible
The following table lists addition codes which describe components or features that can be and frequently are physically incorporated in the specified prefabricated base orthosis. Addition codes may be separately payable if:
• They are provided with the related base code orthosis; and
• The base orthosis is reasonable and necessary; and
• The addition is reasonable and necessary.
Addition codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and necessary or the addition is not reasonable and necessary.
Base Code Addition Codes – Eligible for Separate Payment
L1810 None
L1820 None
L1830 None
L1831 None
L1832 L2397, L2795, L2810
L1836 None
L1843 L2385, L2395, L2397
L1845 L2385, L2395, L2397, L2795
L1847 None
L1850 L2397
The following table lists addition codes which describe components or features that can be physically incorporated in the specified prefabricated base orthosis but are considered not reasonable and necessary. These addition codes, if they are billed with the related base code, will be denied as not reasonable and necessary.
Base Code Addition Codes – Not Reasonable and Necessary
L1810 L2397
L1820 L2397
L1830 L2397
L1831 L2397, L2795
L1832 L2405, L2415, L2492, L2785
L1836 L2397
L1843 L2405, L2492, L2785
L1845 L2405, L2415, L2492, L2785

L1847 L2397, L2795
L1850 L2275
Refer to the related Policy Article for information on addition codes that are considered not separately payable or incompatible with prefabricated knee orthosis base codes.
CUSTOM FABRICATED KNEE ORTHOSES (L1834, L1840, L1844, L1846, L1860):
A custom fabricated orthosis is covered when there is a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations which meet the criterion for a custom fabricated orthosis include, but are not limited to:
1. Deformity of the leg or knee;
2. Size of thigh and calf;
3. Minimal muscle mass upon which to suspend an orthosis.
Although these are examples of potential situations where a custom fabricated orthosis may be appropriate, suppliers must consider prefabricated alternatives such as pediatric knee orthoses in patients with small limbs, straps with additional length for large limbs, etc.
If a custom fabricated orthosis is provided but the medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the custom fabricated orthosis will be denied as not reasonable and necessary.
Custom fabricated orthoses (L1834, L1840, L1844, L1846, L1860) are not reasonable and necessary in the treatment of knee contractures in cases where the patient is nonambulatory.
Custom fabricated orthoses (L1834, L1840, L1844, L1846, L1860) are not medically necessary in the treatment of knee contractures in cases where the patient is nonambulatory.
A custom fabricated knee immobilizer without joints (L1834) is covered if criteria 1 and 2 are met:
The coverage criteria for the prefabricated orthosis code L1830 are met; and
The general criterion for a custom fabricated orthosis is met.
If an L1834 orthosis is provided and both criteria 1 and 2 are not met, the orthosis will be denied as not reasonable and necessary.
A custom fabricated derotation knee orthosis (L1840) is covered for instability due to internal ligamentous disruption of the knee (717.81–717.9).
A custom fabricated knee orthosis with an adjustable flexion and extension joint (L1844, L1846) is covered if criteria 1 and 2 are met:
1. The coverage criteria for the prefabricated orthosis codes L1843 and L1845 are met; and 2. The general criterion for a custom fabricated orthosis is met.
If an L1844 or L1846 orthosis is provided and both criteria 1 & 2 are not met, the orthosis will be denied as not reasonable and necessary.
A custom fabricated knee orthosis with a modified supracondylar prosthetic socket (L1860) is covered for a patient who is ambulatory and has knee instability due to genu recurvatum – hyperextended knee (736.5).
The following table lists addition codes which describe components or features that can be and frequently are physically incorporated in the specified custom fabricated base orthosis. Addition codes may be separately payable if:
• They are provided with the related base code orthosis; and
• The base orthosis is reasonable and necessary; and
• The addition is reasonable and necessary.
Addition codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and necessary or the addition is not reasonable and necessary.
Base Code Addition Codes – Eligible for Separate Payment
L1834 L2795
L1840 L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2785, L2795
L1844 L2385, L2390, L2395, L2397, L2405, L2492, L2785
L1846 L2385, L2390, L2395, L2397, L2405, L2415, L2492, L2785, L2795, L2800
L1860 None
The following table lists addition codes which describe components or features that can be physically incorporated in the specified custom fabricated base orthosis but are considered not reasonable and necessary. These addition codes, if they are billed with the related base code, will be denied as not reasonable and necessary.
Base Code Addition Codes – Not Reasonable and Necessary
L1834 L2397, L2800
L1840 L2275, L2800
L1844 None
L1846 None
L1860 L2397
Refer to the related Policy Article for information on addition codes that are considered not separately payable or incompatible with custom fabricated knee orthosis base codes.
MISCELLANEOUS:
Heavy duty knee joint codes (L2385, L2395) are covered only for patients who weigh more than 300 pounds.
Coverage of a removable soft interface (K0672) is limited to a maximum of two (2) per year beginning one (1) year after the date of service for initial issuance of the orthosis. Additional replacement interfaces will be denied as not reasonable
and necessary. Refer to the Coding Guidelines section of the related Policy Article for information on denial of removable soft interfaces that are billed separately at the time of initial issue of the orthosis.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under
other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
GroupName
The appearance of a code in this section does not necessarily indicate coverage.

  • HCPCS MODIFIERS:
    EY – No physician or other licensed health care provider order for this item or service
    GA – Waiver of liability statement issued as required by payer policy, individual case
    GZ – Item or service expected to be denied as not reasonable and necessary
    KX – Requirements specified in the medical policy have been met
    LT – Left side
    RT – Right side
  • HCPCS CODES:
    A4466 GARMENT, BELT, SLEEVE OR OTHER COVERING, ELASTIC OR SIMILAR
    STRETCHABLE MATERIAL, ANY TYPE, EACH
    A9270 NON-COVERED ITEM OR SERVICE
    K0672 ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS, REPLACEMENT ONLY, EACH
    L1810 KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND
    ADJUSTMENT
    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,
    INCLUDES FITTING AND ADJUSTMENT
    L1831 KNEE ORTHOSIS, LOCKING KNEE JOINT, POSITIONAL ORTHOSIS,
    PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
    L1832
    KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC),
    POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND
    ADJUSTMENT
    L1834 KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATED
    L1836 KNEE ORTHOSIS, RIGID, WITHOUT JOINT, INCLUDES SOFT INTERFACE MATERIAL,
    PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
    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, INCLUDES FITTING AND ADJUSTMENT
    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, INCLUDES FITTING AND ADJUSTMENT
    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, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
    L1850 KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, INCLUDES FITTING AND
    ADJUSTMENT
    L1860 KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET,
    CUSTOM-FABRICATED (SK)
    L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC
    MODIFICATION, PADDED/LINED
    L2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED
    ORTHOSIS ONLY
    L2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR
    CUSTOM FABRICATED ORTHOSIS ONLY
    L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT
    L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT
    L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT
    L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE
    L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACH
    L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE,
    OR EQUAL), ANY MATERIAL, EACH JOINT
    L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION,
    EACH JOINT
    L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE
    EXTENSION, EACH JOINT
    L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING
    L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER
    BAR
    L2755
    ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT
    MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR
    CUSTOM FABRICATED ORTHOSIS ONLY
    L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR
    L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH
    L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP
    L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL
    OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY
    L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD
    L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED
    PLASTIC, BELOW KNEE SECTION
    L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED
    PLASTIC, ABOVE KNEE SECTION
    L2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED
    L4002 REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH,
    ANY TYPE
    L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES
    L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS
    L9900 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT
    OF ANOTHER HCPCS “L” CODE
    ICD-9 Codes that Support Medical Necessity
    The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on
    “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.
  • For HCPCS codes L1830, L1834:
    714.0 – 714.4 RHEUMATOID ARTHRITISCHRONIC POSTRHEUMATIC ARTHROPATHY
    715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG
    715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG
    715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY
    INVOLVING LOWER LEG
    715.96 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
    INVOLVING LOWER LEG
    717.0 – 717.5 OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUSDERANGEMENT OF MENISCUS
    NOT ELSEWHERE CLASSIFIED
    717.7 CHONDROMALACIA OF PATELLA
    717.81 – 717.9 OLD DISRUPTION OF LATERAL COLLATERAL LIGAMENTUNSPECIFIED INTERNAL
    DERANGEMENT OF KNEE
    727.65 NONTRAUMATIC RUPTURE OF QUADRICEPS TENDON
    733.15 PATHOLOGICAL FRACTURE OF OTHER SPECIFIED PART OF FEMUR
    733.16 PATHOLOGICAL FRACTURE OF TIBIA OR FIBULA
    733.49 ASEPTIC NECROSIS OF OTHER BONE SITES
    733.93 STRESS FRACTURE OF TIBIA OR FIBULA
    755.64 CONGENITAL DEFORMITY OF KNEE (JOINT)
    821.20 – 821.39 FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART CLOSEDOTHER
    FRACTURE OF LOWER END OF FEMUR OPEN
    822.0 – 822.1 CLOSED FRACTURE OF PATELLAOPEN FRACTURE OF PATELLA
    823.00 – 823.42 CLOSED FRACTURE OF UPPER END OF TIBIATORUS FRACTURE OF FIBULA WITH
    TIBIA
    836.0 – 836.69 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENTOTHER
    DISLOCATION OF KNEE OPEN
    844.0 – 844.2 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEESPRAIN OF CRUCIATE
    LIGAMENT OF KNEE
    844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG
    996.40 – 996.49
    UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE,
    IMPLANT, AND GRAFTOTHER MECHANICAL COMPLICATION OF OTHER INTERNAL
    ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT
    996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS
    996.77 OTHER COMPLICATIONS DUE TO INTERNAL JOINT PROSTHESIS
    V43.65 KNEE JOINT REPLACEMENT
  • For HCPCS Code L1840:
    717.81 – 717.9 OLD DISRUPTION OF LATERAL COLLATERAL LIGAMENTUNSPECIFIED INTERNAL
    DERANGEMENT OF KNEE
  • For HCPCS Codes L1850, L1860:
    736.5 GENU RECURVATUM (ACQUIRED)
    Diagnoses that Support Medical Necessity
    For the specific HCPCS codes indicated above, refer to the previous section. For all other HCPCS codes, diagnoses are not specified.
    ICD-9 Codes that DO NOT Support Medical Necessity
    For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the previous section.
    ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
    Diagnoses that DO NOT Support Medical Necessity
    For the specific HCPCS codes indicated above, all diagnoses that are not specified in the previous section.For all other
    HCPCS codes, diagnoses are not specified.
  • General Information
    Documentations Requirements
    Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider”. It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.
    An order for all items must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code. Orders must be sufficiently detailed including all options or additional features that will be separately billed. Written orders for custom fabricated orthoses must specifically state “custom fabricated” or specify a brand name and model that is only available as a custom fabricated product.
    The ICD-9 code that justifies the need for the item must be included on the claim.
    KX, GA, GZ MODIFIERS
    Suppliers must add a KX modifier to the knee orthosis base and addition codes only if all of the coverage criteria in the “Indications and Limitations of Coverage and or Medical Necessity” section of this policy have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon
    request.
    If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.
    Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.
    MISCELLANEOUS
    For custom fabricated orthoses (L1834, L1840, L1844, L1846, L1855-L1880), there must be detailed documentation in the orthotist’s records to support the medical necessity of custom fabricated rather than a prefabricated orthosis. This information must be available upon request.
    When billing L2999, the following information should accompany the claim: manufacturer’s name; product name; justification of patient’s medical necessity for the item. In addition, if the item is custom fabricated, a complete and clear description of the item, including what makes this item unique, and a breakdown of charges (material and labor used in fabrication) must be included with the claim.
    An order is not necessary for the repair of an orthosis; however, claims for code L4210 must be accompanied by a description of the part that is being repaired or replaced. This information should be entered into the narrative field on an electronic claim. Refer to the Supplier Manual for more information on documentation requirements.
    Appendices
    Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.
    Sources of Information and Basis for Decision
    Advisory Committee Meeting Notes
    Start Date of Comment Period 09/10/2004
    End Date of Comment Period 10/25/2004
    Start Date of Notice Period 03/20/2008
    Revision History Number KNE001
    Revision History Explanation Revision Effective Date: 07/01/2011
    ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
    Added: ICD-9 codes 342.91 and 342.92 for L1832, L1843 – L1846
    Revision Effective Date: 02/04/2011
    INDICATIONS AND LIMITATIONS OF COVERAGE:
    Deleted: Least costly alternative for multiple HCPCS codes
    HCPCS CODES AND MODIFIERS:
    Added: Code L4002
    Revised: GA modifier
    ICD-9 COES THAT SUPPORT MEDICAL NECESSITY:
    Added: ICD-9 code 844.8 for codes L1830, L1832, L1834 and L1843-L1846
    Revision Effective Date: 01/01/2010
    INDICATIONS AND LIMITATIONS OF COVERAGE:
    Added: Coverage criteria for L1810, L1820.
    Added: Definition for knee instability.
    Revised: Coverage criteria for L1832.
    HCPCS CODES AND MODIFIERS:
    Deleted: L1800, L1815, L1825
    Added: A4466
    ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
    Revised: Covered diagnoses for L1832.
    Revision Effective Date: 12/01/2009
    HCPCS CODES AND MODIFIERS:
    Added: GA/GZ modifiers.
    Revised: RT/LT descriptors.
    DOCUMENTATION REQUIREMENTS:
    Added: Instructions for GA/GZ modifier use.
    Revision Effective Date: 04/01/2009
    INDICATIONS AND LIMITATIONS OF COVERAGE:
    Added: ICD-9 diagnosis codes 844.0 – 844.2 and 996.40 – 996.49 to range of codes for L1830, L1832, L1834, L1843, L1844, L1845 and L1846 in response to request for reconsideration.
    Deleted: Codes L1800, L1815, L1825 from prefabricated knee orthoses.
    Deleted: Codes L1800, L1815, L1825 from Base code & Addition Codes – Eligible for Separate Payment.
    Deleted: Codes L1800, L1815, L1825 from Base code & Addition Codes – Not Medically Necessary.
    ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
    Added: ICD-9 diagnosis codes 844.0 – 844.2 and 996.40 – 996.49 to range of codes for L1830, L1832, L1834, L1843, L1844, L1845 and L1846.
    DOCUMENTATION:
    Added: Clarified that use of KX modifier is applicable to both the base and addition codes.
    Revised: Changed DMERC to DME MAC.
    Revision Effective Date: 07/01/2008
    HCPCS CODES:
    Added: K0672