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Linda Collins Blogger

Post OP Knee Bracing Coverage Criteria

Posted by Linda Collins | April 27, 2018

Medical Necessity requirements for post-operative knee bracing are outlined in the Local Coverage Determination (LCD.)

Medical Necessity

HCPCS codes L1830, L1832, L1833, L1843, L1845, L1851, L1852 may be covered when the following criteria is documented in the patient's medical record:

  • Patient is ambulatory
  • Recent injury or surgery to the knee(s)
  • An appropriate ICD-10 diagnosis code, as listed in the LCD, is present.

Braces billed under L1830 have a reasonable useful lifetime (RUL) of one year. L1832 and L1833 braces have a two year RUL. All other knee braces billed using the codes listed above have an RUL of three years.

A suspension sleeve, billed under HCPCS code L2397, may be billed separately as a component of the post-op brace.

Same and Similar

According to Medicare, many braces are considered Same and Similar. This means that if a patient is given an Unloader Brace billed under L1843 and then with in the three-year RUL the patient undergoes surgery, the post-op brace may be considered "same and similar" and be denied. However, Medicare makes it clear that exceptions to the same and similar rule can be made when there is a well-documented physiological change in the patient. In this situation, be sure to document the patient's condition, the need for a post-op brace, and the reason the original brace is no longer adequate for the patient's need.

Custom Fit Brace

HCPCS L1832, L1843, and L1845 are custom fit codes. 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.

Modifiers

All Knee Orthoses claims require the following modifiers:

  • KX - Requirements specified in the medical policy have been met
  • LT - Left side and/or
  • RT - Right side

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