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Linda Collins Blogger

New Recovery Auditor Issue for Knee Orthoses

Posted by Linda Collins | September 20, 2018

Performant Recovery, DMEPOS Recovery Auditor, Region 5, published a new audit issue regarding Custom Fabricated Knee Orthoses billed with HCPCS L1844 and L1846.

Effective September 14, 2018, custom knee orthoses claims submitted within the past three years may be subject to audit. Specifically, the auditor will be reviewing claims documentation to determine if the medical records adequately detail the medical necessity of a custom brace.

Custom knee braces are made specifically for one patient. The physician's medical record must indicate the reason for a custom brace and must include the following elements:

  • Patient has had a recent injury to or surgery on the knee
  • Patient is ambulatory
  • Knee instability is objectively documented

AND there is documented physical characteristics that precludes use of a prefabricated device such as:

  • Deformity of the leg or knee
  • Size of thigh and calf
  • Minimal muscle mass
  • Chronic condition (longer than six months)
  • Documented neurological, circulatory or orthopedic status.

In addition to the detailed medical records from the physician, the prescription MUST specifically state "custom knee brace."

What does this mean for you?

Be sure your protocols include thorough review of documentation for custom knee braces.

If you do get a letter stating a claim is being audited, be sure to respond.

Learn more about custom knee brace requirements from the LCD and Policy Article here.

Read more about Performant Recovery and the audit issues here.

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