CMS Recovery Auditors Target Documentation and HCPCS Coding for Knee Orthoses

The newsletter outlines key differences between off-the-shelf (OTS), custom fitted, and custom fabricated knee orthoses, which dictate HCPCS coding and billing for these items. 

A version of this article was first published March 22, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Physician and non-physician practitioners may benefit from reviewing documentation requirements and HCPCS Level II codes for knee orthoses, according to a recent Medicare Quarterly Compliance Newsletter.

Medicare Recovery Auditors have found that suppliers are at risk of furnishing knee orthoses to beneficiaries in situations that do not meet coverage requirements. The newsletter reminds providers that knee orthoses must be capable of providing the necessary immobilization or support to the body part for which it is designed to be covered under Medicare.

The newsletter outlines key differences between off-the-shelf (OTS), custom fitted, and custom fabricated knee orthoses, which dictate HCPCS coding and billing for these items. Providers should review these differences as well as coding considerations for each type of orthosis to prevent denials for these services.

OTS orthotics

OTS orthotics are prefabricated and require minimal self-adjustment for final fitting at the time of delivery. They do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual, according to Local Coverage Article (LCA) A52465.

HCPCS codes for these services include the language, “prefabricated, off-the-shelf.” For example, HCPCS code L1812 (knee orthosis, elastic with joints, prefabricated, off-the-shelf) is used to report a specific OTS orthotic.

Custom fitted orthotics

Custom fitted knee orthotics are prefabricated and require more than minimal self-adjustment at the time of delivery to provide an individualized fit (i.e., the item must be trimmed, bent, and/or molded), according to LCA A52465.

HCPCS code descriptors for these services include the language, “prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.” For example, HCPCS code 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) is used to report a specific custom fitted knee orthosis.

Custom fabricated orthotics

Custom fabricated items are individually made for a specific patient and fabricated based on clinically derived and rectified castings, tracings, measurements, and/or other images of the body part, according to LCA A52465.

To support medical necessity for a custom-fabricated knee orthosis, the provider must document a physical characteristic that requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations that meet the criterion for a custom fabricated orthosis include:

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

The provider must report an ICD-10-CM diagnosis code that necessitates the need for the knee orthosis.

HCPCS codes for custom fabricate orthotics specify the type of orthosis and joint functions that it supports. For example, HCPCS code L1844 (knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated) is used to report a custom fabricated knee orthosis that extends to the thigh and calf and that provides medial-lateral rotation control.