Two New “K” Codes for Prefabricated Single and Double Upright Knee Orthoses Furnished Off-The-Shelf - Revised

MLN Matters® Number: MM8839 Revised
Related Change Request (CR) #: CR 8839
Related CR Release Date: August 26, 2014
Effective Date: October 1, 2014
Related CR Transmittal #: R3052CP
Implementation Date: October 6, 2014

This article was revised on August 28, 2014, to reflect the revised CR8839 issued on August 26, 2014. In the article, the CR release date, transmittal number, and the Web address for accessing the CR are revised. All other information remains the same.

Provider Types Affected

ThisMLN Matters® Article is intended for suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

Change Request (CR) 8839 announces that, effective October 1, 2014, two new "K" codes (K0901 and K0902) will be established for Prefabricated Single and Double Upright Knee Orthoses That Are Furnished Off-The-Shelf (OTS). The addition of these codes will allow the DME MACs to correctly adjudicate claims. Make sure your billing staffs are aware of these changes.

Background

Definitions

  • The orthotics currently paid under Section 1834(h) (Payment for Prosthetic Devices and Orthotics and Prosthetics) of the Social Security Act (the Act), and that are described in its Section 1861(s)(9) (Part E - Miscellaneous Provisions, Definitions of Services, Institutions, etc.) are leg, arm, back, and neck braces. (You can find these sections of the Act at http://www.ssa.gov/OP_Home/ssact/title18/1834.htm, and http://www.ssa.gov/OP_Home/ssact/title18/1861.htm, respectively).
  • The "Medicare Benefit Policy Manual," Chapter 15 (Covered Medical and Other Health Services), Section 130 (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) provides the longstanding Medicare definition of "braces" as "rigid or semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body." (You can find this manual section at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf on the CMS website).
  • Further, Section 1847(a)(2) of the Act defines OTS orthotics as those for which payment would otherwise be made under Section 1834(h), above; which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual. You can find this section of the act at http://www.ssa.gov/OP_Home/ssact/title18/1847.htm.
  • Lastly, the Center for Medicare & Medicaid Services (CMS) regulations at 42 CFR 414.402, which you can find at http://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol3/html/CFR-2007-title42-vol3-sec414-402.htm, define the term "minimal self-adjustment" as "an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform; and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training."

New OTS Orthotics Healthcare Common Procedure Coding System (HCPCS) Codes

In February 2012, CMS issued guidance that initially identified specific HCPCS codes that were considered OTS orthoses. The list of HCPCS codes that were finalized as part of this review as OTS orthotics, effective January 1, 2014, are available for download at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/OTS_Orthotics on the CMS website.

CR8839 announces that in order to identify prefabricated single and double upright knee orthoses that are furnished in a variety of standard sizes and do not require the skills of an expert to measure and fit to the individual; the following OTS codes will be added to the HCPCS code set, effective October 1, 2014:

  • K0901- Knee orthosis (KO), 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, off-the-shelf; and
  • K0902 -Knee orthosis (KO), 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, off-the-shelf;

Additional Information

The official instruction, CR8839 issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3052CP.pdf on the CMS website.

 

            Last Updated Tue, 04 Feb 2020 14:24:14 +0000