Skip navigation
9

Linda Collins Blogger

Knee Orthoses Audit Results

Posted by Linda Collins | January 08, 2015

​Noridian, Region D DMEMAC, just released the results of prepayment audits on HCPCS codes L1832, L1833, and L1843.


The L1832 review involved 111 claims, of which 111 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100%.

The L1833 review involved 100 claims, of which 99 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 98%.

The L1843 review involved 106 claims, of which 106 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100%.
 
The main reasons for denial stem from a lack of documentation outlining the medical necessity requirements as stated in the LCD (Local Coverage Determination, L27058, Knee Orthoses.)
  • The documentation must show that knee instability is present and include an objective description of joint laxity is included.
  • The documentation must indicate the beneficiary has had a recent injury or surgery to the knee. The braces are also covered if the beneficiary is ambulatory and has been recently diagnosed with one of the following ICD-9 codes:
 
340 MULTIPLE SCLEROSIS
342.90 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.91 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.92 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED
344.1 PARAPLEGIA
355.0 LESION OF SCIATIC NERVE
355.2 OTHER LESION OF FEMORAL NERVE
714.0 - 714.4 RHEUMATOID ARTHRITIS - CHRONIC POSTRHEUMATIC ARTHROPATHY
715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG
715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG
715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING LOWER LEG
715.96 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING LOWER LEG
717.0 - 717.5 OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUS - DERANGEMENT OF MENISCUS NOT ELSEWHERE CLASSIFIED
717.7 CHONDROMALACIA OF PATELLA
717.81 - 717.9 OLD DISRUPTION OF LATERAL COLLATERAL LIGAMENT - UNSPECIFIED INTERNAL DERANGEMENT OF KNEE
727.65 NONTRAUMATIC RUPTURE OF QUADRICEPS TENDON
727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON
733.15 PATHOLOGICAL FRACTURE OF OTHER SPECIFIED PART OF FEMUR
733.16 PATHOLOGICAL FRACTURE OF TIBIA OR FIBULA
733.49 ASEPTIC NECROSIS OF OTHER BONE SITES
733.81 - 733.82 MALUNION OF FRACTURE - NONUNION OF FRACTURE
733.93 STRESS FRACTURE OF TIBIA OR FIBULA
755.64 CONGENITAL DEFORMITY OF KNEE (JOINT)
821.20 - 821.39 FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART CLOSED - OTHER FRACTURE OF LOWER END OF FEMUR OPEN
822.0 - 822.1 CLOSED FRACTURE OF PATELLA - OPEN FRACTURE OF PATELLA
823.00 - 823.42 CLOSED FRACTURE OF UPPER END OF TIBIA - TORUS FRACTURE OF FIBULA WITH TIBIA
836.0 - 836.69 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT - OTHER DISLOCATION OF KNEE OPEN
844.0 - 844.2 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE - SPRAIN OF CRUCIATE LIGAMENT OF KNEE
844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG
905.4 LATE EFFECT OF FRACTURE OF LOWER EXTREMITIES
996.40 - 996.49 UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT - OTHER MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT
996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS
996.77 OTHER COMPLICATIONS DUE TO INTERNAL JOINT PROSTHESIS
V43.65 KNEE JOINT REPLACE
 
 L1832 and L1843 describe knee orthoses that are custom-fit. Custom fitted orthotics require substantial modification in order to provide an individualized fit. The specific modifications must be documented, in detail, in the patient’s medical record. (Clarification that Confuses, New K Codes, What you need to know to be Ok.)

What does this mean for you?

You and your staff must have a thorough knowledge of the details outlined in the LCDs and Policy Articles. Your documentation must be detailed, timely, objective and available for review upon request. Further resources are available to you under “Reimbursement Resources." These codes are likely to continue receiving close scrutiny so protect yourself by knowing the requirements for billing.
 
Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com