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Coding Guidelines for Knee Orthoses Addition Codes

National Government Services, the Jurisdiction B DME MAC has identified a trend in the inappropriate billing of incompatible knee orthoses addition codes. When incompatible addition codes are submitted for knee orthoses base codes, suppliers will receive an ANSI 96 (noncovered) denial with the alert message “You may not appeal this decision.” Despite the alert message on the supplier’s remittance advice, the Jurisdiction B DME MAC appeals department has received an increase in request for redeterminations for incompatible addition codes. These types of denials may not be appealed and should not be submitted as a request for redetermination. Suppliers may resubmit the claim with the correct compatible knee orthoses addition code.

The local medical policy indicates that addition codes, which describe components or features that, can be and frequently are physically incorporated in prefabricated base orthoses, are separately payable when they are provided with a related base code orthoses, the orthosis is deemed reasonable and necessary and the addition is reasonable and necessary. Addition codes will be denied as not reasonable and necessary if the base orthosis or the addition is not reasonable and necessary.

The table below provides a list of knee orthoses base codes and the appropriate addition code that is eligible for separate payment when both the knee brace and addition are deemed reasonable and necessary.

Base Code Addition Codes - Eligible for Separate Payment
L1810 None
L1820 None
L1830 None
L1831 None
L1832 L2397, L2795, L2810
L1836 None
L1843 L2385, L2395, L2397
L1845 L2385, L2395, L2397, L2795
L1847 None
L1850 L2397

Suppliers are responsible for ensuring that the base code and addition code are compatible and considered reasonable and necessary according to policy. The table below lists addition codes which describe components or features that can be physically incorporated in the specified prefabricated base orthosis but are considered not reasonable and necessary. Although the additions may be physically incorporated to the base, if they are billed with the related base code, they will be denied as not reasonable and necessary.

Base Code Addition Codes - Not Reasonable and necessary
L1810 L2397
L1820 L2397
L1830 L2397
L1831 L2397, L2795
L1832 L2405, L2415, L2492, L2785
L1836 L2397
L1843 L2405, L2492, L2785
L1845 L2405, L2415, L2492, L2785
L1847 L2397, L2795
L1850 L2275

These same rules apply to custom fabricated knee orthoses. The addition codes will be denied as not reasonable and necessary if the base orthosis or the addition is not reasonable and necessary. The table below identifies the base and addition codes that are eligible for separate payment.

Base Code Addition Codes - Eligible for Separate Payment
L1834 L2795
L1840 L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2785, L2795
L1844 L2385, L2390, L2395, L2397, L2405, L2492, L2785
L1846 L2385, L2390, L2395, L2397, L2405, L2415, L2492, L2785, L2795, L2800
L1860 None

The following table lists addition codes which describe components or features that can be physically incorporated in the specified custom fabricated base orthosis but are considered not reasonable and necessary. These addition codes, if they are billed with the related base code, will be denied as not reasonable and necessary.

Base Code Addition Codes - Not Reasonable and Necessary
L1834 L2397, L2800
L1840 L2275, L2800
L1844 None
L1846 None
L1860 L2397

The following table lists addition codes which describe components or features that can be physically incorporated in the specified prefabricated bases orthosis but are considered to be included in the allowance for the orthosis. The addition codes will be denied as not separately payable if they are billed with the related base code.

Base Code Addition Codes - Not Separately Payable
L1834 K0672, L2820, L2830, L4002
L1840 K0672, L2320, L2330, L2750, L2780, L2810, L2820, L2830, L4002
L1844 K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1846 K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1860 K0672, L2820, L2830, L4002

Addition codes that are not listed as either separately payable or not medically necessary in the LCDs describe components or features that either cannot be physically incorporated or whose narrative description is incompatible with the specified base orthosis code (e.g., billing a prefabricated base code with an addition code which specifies that the addition code is it only used with custom fabricated orthoses). These incompatible addition codes will be rejected as incorrect coding. Suppliers may resubmit their claim with the appropriate addition code when applicable. As a reminder appeal rights are not afforded on claims rejected due to incorrect coding.

For additional details regarding the LCD for knee orthoses please visit the National Government Services Web site.

Coding Guidelines for Knee Orthoses Addition Codes
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