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Linda Collins Blogger

OA Bracing: Coding

Posted by Linda Collins | June 12, 2014

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. The good news is OA bracing may prevent or delay costly surgery. Providing OA Braces to patients is an easy and viable option that provides immediate results.

Are you familiar with the coding, coverage and reimbursement issues associated with the Unloader OA Knee Brace? In this three part series, we will discuss the basics involved in documenting and submitting Unloader OA Knee Brace claims to Medicare and private insurers.

Base Codes

There are several code and product options for OA Knee Bracing:

  • L1843 Trainer OA*
  • L1845 OAsys*
  • L1843 Unloader One
  • L1843 Unloader Spirit
  • L1844 Unloader One Custom
  • L1843 Unloader One Plus
  • L1844 Unloader Custom
  • L1846 CTi OA*

*PDAC verified.

The responsibility for accurate coding lies solely with the provider treating the patient. Ossur assumes no responsibility or liability for the provider's coding decision. Ossur's coding suggestions rest on its best judgment and are subject to revision based on additional information or changes in the alpha-numeric system.

The most commonly used codes are L1843 (Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise) and L1845 (Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.) "Custom-fit" items like those described by these codes require "substantial modification" for fitting at the time of delivery in order to provide an individualized fit. This means the item must be trimmed, bent, molded, or otherwise modified resulting in alterations beyond minimal self-adjustment. (See“Code Confusion & OTS Orthotics,” Ossur R&R, April 10, 2014)

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.

Coding Verification

The only products billable using code L1845 are those for which the Pricing, Data Analysis, and Coding (PDAC) contractor has made a written coding verification. Check the website, www.dmepdac.com, to check the product listing prior to claims submission.

Next in the series will be a discussion on coverage requirements for OA Bracing.

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