Article - Knee Orthoses - Policy Article (A52465)

L1820L2390, L2750, L2780, L2810, L4002L1830K0672, L4002L1831K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1832K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002L1833K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002L1836K0672, L2750, L2780, L2810, L2820, L2830, L4002L1843K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1845K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1847K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1848K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1850K0672, L2750, L2780, L2810, L2820, L2830, L4002L1851K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1852K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002The following table lists addition codes which describe components or features that can be physically incorporated in thespecified custom fabricated base orthosisbut are considered to be included in the allowance for the orthosis. The addition codes will be denied as not separately payable if they are billed with the related base code.Base CodeAddition Codes - Not Separately PayableL1834K0672, L2820, L2830, L4002L1840K0672, L2320, L2330, L2750, L2780, L2810, L2820, L2830, L4002L1844K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1846K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1860K0672, L2820, L2830, L4002All addition codes that are not listed as either separately payable or not reasonable and necessary in the tables in the LCD or as not separately payable in the tables above, describe components or features that either cannot be physically incorporated in the specified base orthosis or whose narrative description is incompatible with base orthosis code (e.g., billing a prefabricated base code with an addition code which specifies that it is only used with custom fabricated orthoses). These incompatible addition codes will be rejected as incorrect coding.L-coded additions to knee orthoses (L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, K0672) will be denied as noncovered when the base orthosis is noncovered.A replacement removable soft interface for a knee orthosis is billed with code K0672 (ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS, REPLACEMENT ONLY, EACH). One unit of service includes all the components that are used at the same time on a single orthosis.Either a nonremovable soft interface, 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), or two (2) removable soft interfaces (K0672) are included in the allowance for a knee orthosis. Soft interfaces billed separately at the time of initial issue will be denied as not separately payable.Codes L2320 (ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY) and L2330 (ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY), non-molded and molded lacers, respectively, may only be billed as replacement items.CONCENTRIC TORSION JOINTSAll claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint for any condition other than an assistive function to joint extension motion must be coded as durable medical equipment using code E1810 (DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). If a concentric adjustable torsion style mechanism in the knee joint is used solely to provide an assistive function for joint extension, it must be coded as L2999 (See the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).Claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint and that are being used to treat any condition other than an assistive function to joint extension motion are not covered under the braces benefit and will be denied as incorrect coding when billed using code L2999 (See the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).REPAIR/REPLACEMENTCode L4205 (REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES) may only be billed for time involved with the actual repair of an orthosis or for medically necessary adjustments made more than 90 days after delivery. Code L4205 must not be used to bill for time involved with other professional services including, but not limited to:Evaluating the beneficiaryTaking measurements, making a cast, making a model, use of CAD/CAMMaking modifications to a prefabricated item to fit it to the individual beneficiaryFollow-up visitsMaking adjustments at the time of or within 90 days after deliverySuppliers must distinguish between repair and replacement of an orthosis. When an orthotic is replaced, there is no separate billing for the above services because reimbursement for these services is included in the allowance for the replacement item.Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier's record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.The allowance for the labor involved in replacing/repairing an orthotic component that is coded with a specific L-code is included in the allowance for that component. The allowance for the labor (L4205) involved in replacing/repairing an orthotic component that is coded with the miscellaneous code L4210 (REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS) is separately payable in addition to the allowance for that component. (Code L4210 must not be used for casting supplies or other materials used in the fitting or fabrication of an orthosis.)The following chart reflects the reasonable useful lifetime of prefabricated knee orthoses:L18101 yearL18121 yearL18201 yearL18301 yearL18312 yearsL18322 yearsL18332 yearsL18363 yearsL18433 yearsL18453 yearsL18502 yearsL18513 yearsL18523 yearsThe reasonable useful lifetime of a custom fabricated orthosis is 3 years.Replacement during the reasonable useful lifetime, is covered if the item is lost or irreparably damaged. Replacement for other reasons, including but not limited to irreparable wear, during the period of reasonable useful lifetime is denied as noncovered.Addition codes K0672, L2390, L2750, L2780, L4002 are for billing of replacement component(s) and are not payable at initial issue of a base orthosis. When code L4002 is billed at the time of initial issue of a base orthosis, it will be denied as not separately payable.Should a supplier wish to submit a claim for services/items that are included in the allowance for the orthosis, code L9900 (ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE) must be used. Code L9900 is denied as not separately payable.Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC web site or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC web site. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after July 1, 2008:L1845Effective for claims with dates of service on or after January 1, 2017:L1852Effective for claims with dates of service on or after October 10, 2022:L1832, L1833 and L1851If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.