The Centers for Medicare & Medicaid Services (CMS) has released a Dear Physician letter with summary guidance information on Medicare's coverage and documentation requirements for knee orthoses.
According to the July 2022 letter "Knee orthoses have consistently been one of the highest sources of errors in medical reviews performed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Comprehensive Error Rate Testing (CERT) contractor."
The CMS Dear Physician Knee Orthoses Letter is available using this link. This letter, and other Dear Physician letters, can be accessed at the following URL:
https://www.cgsmedicare.com/jb/mr/doc_req.html
CMS understands the importance of educating providers with guidance on Medicare's coverage and determination requirements for DMEPOS (durable medical equipment, prosthetics, orthotics and supplies). The summary guidance letter describes Medicare's requirements for documenting medical necessity of knee orthoses.
Understanding the Medicare knee orthoses coverage and determination requirements, along with the required medical necessity which must be documented, is beneficial to reduce claim denials and rejections.
The summary guidance letter also includes information about HCPCS codes that require prior authorization, face-to-face encounter, and written order prior to delivery. We previously wrote about prior authorization in the blog Prior Authorization Changes for Medicare Off-the-Shelf Knee and Back Braces.
If your office writes for any of the following HCPCS codes you'll want to review the Summary of Coverage Criteria section.
| Prefabricated | Custom Fabricated |
| L1810 | L1834 |
| L1812 | L1840 |
| L1820 | L1844 |
| L1830 | L1846 |
| L1831 | L1860 |
| L1832 | |
| L1833 | |
| L1836 | |
| L1843 | |
| L1845 | |
|
L1850 |
|
|
L1851 |
|
|
L1852 |
A brief summary of the Knee Orthoses LCD is available by clicking this link.
The Knee Orthoses Policy Article is available by clicking this link.
Our Team is ready to answer questions about Medicare coverage for knee orthoses. We have billing and orthoses professionals ready to assist with coverage questions and identifying the proper HCPCS code for your patient's knee orthosis.
Contact us today and take a look at our wide selection of knee orthoses.