OA Knee Brace Coding

Knee osteoarthritis (OA) diagnoses are on the increase. As the population ages and remains active longer, all parts of the health system are looking for alternatives to surgical treatment of OA. In fact, many payers are requiring conservative treatment before authorizing total joint replacement surgery. Knee bracing is typically considered a possible conservative treatment modality  Providing OA braces to patients is an easy and viable option that provides immediate results.

Are you familiar with the coding and coverage requirements for Unloader OA Knee Braces?

Off the Shelf (OTS) codes are used to bill the brace when there is "minimal self-adjustment" at the time of fitting. Custom-fit codes are used when there are substantial modifications made to achieve an individualized fit of the item. The substantial modifications must be documented and performed by a certified orthotist or an individual who has equivalent specialized training. The same product may have two codes and it is up to the supplier to determine which code to use, based upon what is done to the product at time of delivery. 

• Unloader OA Knee Brace, OTS, L1851
• Unloader OA Knee Brace, Custom-fit, L1843

If you bill the Custom-fit code, you must have detailed documentation supporting the substantial modifications made to the brace at the time of fitting. Failure to have this documentation may result in a claim denial.

Add-on Codes

A suspension sleeve (L2397) is billable with the base knee brace if there is documented medical necessity such as:

• Skin sensitivity (history, predisposition, concern)
• Moisture management
• Dirt/foreign body barrier (usually ADL related)
• Soft Tissue Containment
• Edema/Swelling control

Heavy-duty knee joints (L2385, L2395) are billable if the patient weighs more than 300 pounds.

Modifiers

Orthotic claims require a modifier to indicate which side of the body the brace will be supporting: "LT" for left side and "RT" for right side. For bilateral braces billed on the same date of service, use a double modifier of "LTRT" with the HCPCS code.

Add a "KX" modifier to knee orthoses base and addition codes if documentation of medical necessity is in the patient's medical record.

Download the Ossur OA Knee Bracing Checklist for more information.