Clinicians! Are You Ordering Knee Orthoses for Your Patients? - JD DME

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are providing helpful guidance to assist suppliers in providing a knee orthosis to your patient. Medicare must be able to verify that there is medical record documentation to support the orthosis you are prescribing.

Medicare coverage requires the patient's medical record to show the orthosis is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Coverage Criteria Documentation Requirements

Knee orthoses coverage criteria are specific to each type of orthosis. The most common knee orthoses ordered require documentation that show the patient has weakness or deformity of the knee and needs stabilization.

• Prefabricated HCPCS Codes L1832, L1833, L1843, L1845, L1851, L1852 and Custom Fabricated HCPCS Codes L1844, L1846 have two potential paths to coverage:
• Recent injury or surgical procedure: Requires that your documentation show the patient has had a recent injury to, or a surgical procedure on, the knee(s). In addition, the medical necessity needs to be supported by one of the ICD-10-CM codes in Group 2 or 4 codes located in the Knee Orthoses Local Coverage Determination (LCD)-related Policy Article (A52465).
• Ambulatory and Knee Instability: Requires your documentation show that the patient is ambulatory and has knee instability. Your examination of the patient and your objective description of joint laxity (such as varus/valgus instability, anterior/posterior Drawer test) are required. In addition, the medical necessity needs to be supported by one of the Group 4 ICD-10-CM codes listed in the Knee Orthoses LCD-related Policy Article (A52465).
• A custom fabricated knee orthosis has the same basic coverage criteria as the same type of prefabricated knee orthosis. However, there must also be documentation in your records to medically describe why your patient needs a custom fabricated device instead of a prefabricated knee orthosis. Review the LCD for specific information regarding custom fabricated orthoses.

For full coverage criteria related to the above HCPCS codes or additional knee orthoses, review the Local Coverage Determination (LCD) and Policy Article.

Medicare requires a Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) for some of these braces. The treating practitioner must complete the WOPD within six months after the face-to-face encounter. (See the Required Face-to-Face Encounter and WOPD List here.)

The SWO/WOPD must contain the elements listed below. Assist your patient by providing the order and documentation to substantiate need in a timely manner. In addition to the "reasonable and necessary" criteria outlined in the LCD there are further payment rules related to documentation requirements. For details related to those documentation requirements, review the Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).

Standard Written Order (SWO) Elements

An order must contain the following elements to be considered a valid SWO:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., knee orthoses), a HCPCS code, a HCPCS code narrative, or a brand name/model number
  • For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
  • For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature

Medicare requires that all HCPCS codes that appear on the Required Prior Authorization List must be submitted for prior authorization before delivery and claim submission.

LCDs and Policy Articles for lower limb orthoses can be located on the DME MAC contractor websites.