Article Detail - JA DME
Billing Reminder for Knee Orthoses Addition Codes
Posted March 18, 2011
Recent reviews performed by the Recovery Audit Contractors (RACs) identified errors in the billing of additions to knee orthoses. Jurisdiction A DME MAC, is providing the following information for suppliers to avoid claim denials for inappropriate billing of knee orthoses addition codes.
The Knee Orthoses Local Coverage Determination (LCD) indicates which addition codes are separately payable when they are provided with a related base code orthoses.
Suppliers are responsible for ensuring that the base code and addition code are compatible and considered reasonable and necessary according to policy.
Addition codes will be denied as not reasonable and necessary if the base orthosis or the addition is not reasonable and necessary.
Prefabricated Knee Orthoses:
The table below provides a list of knee orthoses base codes and the addition codes that are considered as appropriate for use with a given base orthosis.
| 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 |
The table below lists addition codes that 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 |
The following table lists addition codes that describe components or features that can be physically incorporated in the specified prefabricated bases orthosis but are considered 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 |
Custom Fabricated Knee Orthoses:
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 that 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 that describe components or features that can be physically incorporated in the specified custom fabricated bases orthosis but that are considered 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 LCD 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 it is 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 information, see the Knee Orthoses LCD, Policy Article and the Supplier Manual. This information is available through the NHIC DME MAC Jurisdiction A Website.
