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Breaking News for O&P Professionals
March 25, 2008 ♦ Special Edition
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O&P News
Knee Orthoses Medical Policy Issued
The Four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued the long anticipated Local Coverage Decision (LCD) and Policy Article that will govern Medicare coverage of knee orthoses. LCDs and Policy Articles together make up the overall medical policy for a specific benefit category under the Medicare program. While each DME MAC has published their own version of the LCD and Policy Article, the policy itself is identical to ensure consistent coverage rules for all Medicare beneficiaries.

The draft version of the Medicare knee orthosis policy was originally released in Sept. 2004 and was open for public comment until Oct. 25, 2004. After reviewing all of the public comments on this policy, including those submitted by AOPA, the final version of the LCD and Policy Article was released on March 20, 2008 and will go into effect for claims with dates of service on or after July 1, 2008.

AOPA staff have carefully reviewed the LCD and Policy Article and prepared the following highlights:

  1. Knee orthoses with locking joints (L1831, L1847) or rigid knee orthoses (L1836) are restricted to use in the treatment of non-fixed flexion/extension contractures (ICD-9 code 718.46). Medicare defines a non-fixed contracture as one where passive range of motion results in at least 10 degrees of motion in the affected joint. Knee orthoses described by these three codes will be denied as not medically necessary if they are used to treat fixed contractures or other conditions.

  2. Claims for L1847 that meet the coverage criteria for contracture management will be downcoded to L1831. The policy indicates that there is no proven clinical benefit to the inflatable air bladder that is incorporated into the descriptor for L1847.

  3. Coverage of specific knee orthoses are tied to specific diagnoses.

  4. Clearly defines each knee orthosis base code by the type of material used in itsconstruction as well as its intended function.

  5. Classifies knee orthosis addition codes into four categories and contains tables that indicate which addition codes may be billed with each base code. The four categories are:
    1. Eligible for separate payment
    2. Not medically necessary
    3. Not separately payable
    4. Incompatible

  6. Creates specific criteria that must exist in order for a custom fabricated knee orthosis to be covered. Examples of these criteria include:
    1. Deformity of the leg or knee;
    2. Unusual size of the thigh and calf; or
    3. Minimal muscle mass upon which to suspend an orthosis.

  7. Indicates that claims for custom fabricated knee orthoses must be supported by a written order that specifies the provision of a custom fabricated orthosis.

  8. Indicates that heavy duty knee joint codes (L2385 and L2386) are only covered for patients who weigh more than 300 pounds.

  9. Limits the coverage of removable soft interfaces (K0672) to a maximum of two per year beginning one year after the provision of the initial orthosis.

  10. Requires the use of the “KX” modifier on claims for knee orthoses when required coverage criteria have been met.

  11. Establishes the following useful lifetime criteria for knee orthoses:
    1. One year: L1800, L1810, L1815, L1820, L1825, L1830
    2. Two Years: L1831, L1832, L1847, L1850
    3. Three Years: L1836, L1843, L1845, All custom fabricated knee orthoses

  12. Indicates that brace sleeves used in conjunction with knee orthoses are non-covered because they do not meet the definition of a brace.

  13. Establishes a requirement that products billed as L1845 must be approved by SADMERC through a written coding verification.

  14. Indicates that reimbursement for a non removable soft interface (L2820, L2830) or two removable soft interfaces (K0672) are included in the allowance for the base code and are not separately billable when the orthosis is initially provided.

  15. Indicates that L2320 and L2330, which describe lacers, may only be billed as replacement items.

  16. Indicates that the “any material” code (L2770), and the “concentric, adjustable torsion style joint mechanism” code (L2860) are invalid for claim submission and will be denied.
While the synopsis above captures the majority of issues addressed by the LCD and Policy Article, AOPA encourages you to review the entire policy (click here to download) and prepare for its implementation on July 1, 2008.  A complete copy of the LCD and Policy Article may be found at AOPA’s Web site.

Questions? Contact Joe McTernan at jmcternan@AOPAnet.org or (571) 431-0811.
 
AMERICAN ORTHOTIC & PROSTHETIC ASSOCIATION (AOPA)

American Orthotic & Prosthetic Association (AOPA)
330 John Carlyle St., Suite 200, Alexandria, VA 22314
Tel: (571) 431-0876, Fax: (571) 431-0899
www.AOPAnet.org