Jurisdiction C, CGS Medicare, provided details of a recent claims analysis. The top reason for claims denial for braces billed with L1833 and L1851 is a lack of medical records detailing an examination of knee instability and an objective description of joint laxity.
According to the Local Coverage Decision (LCD) Knee Orthosis (L33318), the braces billed with the above HCPCS codes may be covered when the patient is ambulatory and has knee instability. Further, the LCD states “….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).” This instability documentation must be in the physician’s medical records.
What Does This Mean for You?
Be familiar with the instability documentation requirements and educate your referring physicians. Review notes to determine that knee instability is objectively documented. Simply stating “patient has knee instability” is not sufficient.
Össur has several resources to assist you and your team. These resources can be downloaded under the “Reimbursement Resource” section or obtained from your Össur representative.
