Collaborative Knee Orthoses - CGS Medicare · A knee orthosis with a locking knee joint (L1831) or...

Collaborative Knee Orthoses Provider Outreach and Education

December 19, 2018 © 2018 Copyright. This is collaborative education presented by the four DME MAC jurisdictions.

Disclaimer This presentation was current at the time it was published or uploaded onto the Web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees; agents, including CGS and its staff; and CMS’ staff make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

This presentation may not be recorded for any purpose.

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CGS Medicare Website (https://www.cgsmedicare.com)

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Agenda Definitions

Coverage

Documentation Requirements

Repairs and Replacement

Resources

Questions


Definitions


Definitions Orthosis (Brace):

• Rigid or semi-rigid devices 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.

Prefabricated Orthosis: • Both “off-the-shelf” (OTS) and custom-fit items are considered

prefabricated braces for Medicare coding purposes. • Manufactured in quantity without a specific beneficiary in mind.

Custom Fabricated Orthosis: • Individually-made for a specific beneficiary starting with basic material • Involves more than trimming, bending, or making other modifications to

a substantially prefabricated item.


Prefabricated Orthoses Key to correct coding: is there is a need for “minimal self-

adjustment” during the final fitting at the time of delivery?

Any orthosis that does not meet the definition of a custom-fabricated orthosis is considered prefabricated.

Includes both “off-the-shelf” and custom-fit items

There are parallel sets of HCPCS codes that describe identical types of items. • Which code to use depends on how the final fitting is performed

upon delivery.


Definitions Off-the-Shelf (OTS) Orthotics Custom-Fitted Orthotics

Prefabricated Prefabricated

May or may not be supplied as a kit that requires some assembly

May or may not be supplied as a kit that requires some assembly

Requires minimal self-adjustment for fitting (by beneficiary or supplier)

Requires substantial modification for individualized fit

Fitting does NOT require expertise of certified orthotist/specialized training

Fitting DOES require expertise of certified orthotist/specialized training


Minimal Self-adjustment vs. Substantial Modification

Minimal Self-adjustment (Off-the-Shelf)

Substantial Modification (Custom-Fitted)

Beneficiary, caregiver or supplier can perform the adjustment

Changes made to achieve an individualized fit during the final fitting at the time of delivery

DOES NOT REQUIRE certified orthotist or individual with specialized training

DOES REQUIRE certified orthotist or individual with specialized training

Examples: • Adjustment of straps and closures • Bending or trimming for final fit

or comfort

Trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment


Individuals with Expertise to Perform Substantial Modifications

Certified Orthotist Specialized Training

Certified by:

American Board for Certification in Orthotics and Prosthetics, Inc.

or

Board for Orthotics/ Prosthetist Certification

Individuals with specialized training to provide custom-fitting services include:

Physician Treating practitioner:

• Physician assistant • Nurse practitioner • Clinical nurse specialist

Occupational therapist Physical therapist


All must be in compliance with all applicable Federal and State licensure and regulatory requirements.

Custom-Fabricated Individually-made for a specific beneficiary

Fabricated based on clinically-derived and rectified castings, tracings, measurements, and/or other images (such as X-rays) of the body part.

Requires the use of basic materials including, but not limited to: plastic, metal, leather, or cloth in the form of uncut or unshaped sheets, bars, or other basic forms.

Involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing prior to fitting on the beneficiary.

Requires a positive model of the beneficiary.


Coverage


Prefabricated Knee Orthoses A knee orthosis with joints (L1810, L1812) or knee orthosis with

condylar pads and joints with or without patellar control (L1820) are covered for ambulatory beneficiaries who have the following:

• Weakness or deformity of the knee; and,

• Require stabilization.

A knee orthosis with a locking knee joint (L1831) or a rigid knee orthosis (L1836) is covered for beneficiaries with flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture).

• Requires a covered Group 1 diagnosis code.


Prefabricated Knee Orthoses A knee immobilizer without joints (L1830), or a knee orthosis with

adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if:

• The beneficiary has had recent injury to or a surgical procedure on the knee(s).

• Requires a covered Group 2 or Group 4 diagnosis code.

New Code added as of 01/01/17


Prefabricated Knee Orthoses Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are

also covered for a beneficiary who is:

• Ambulatory; and,

• Has knee instability due to a condition specified in the Diagnosis Codes That Support Medical Necessity Group 4 Codes section.


Prefabricated Knee Orthoses Knee orthosis, Swedish type, prefabricated (L1850) is covered for

a beneficiary who is:

• Ambulatory; and,

• Has knee instability due to genu recurvatum – hyperextended knee.

– Congenital or acquired



Prefabricated Knee Orthoses For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852,

knee instability must be documented by:

• Examination of the beneficiary; and,

• Objective description of joint laxity

– (e.g., varus/valgus instability, anterior/posterior Drawer test).

If a knee orthosis is provided but the beneficiary does not meet the criteria for coverage, the orthosis will be denied as not reasonable and necessary.


Custom Fabricated Knee Orthoses (L1834, L1840, L1844, L1846, L1860)

Coverage for a custom fabricated requires a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis.

Examples of situations which meet the criterion for a custom fabricated orthosis include, but are not limited to:

• Deformity of the leg or knee;

• Size of thigh and calf;

• Minimal muscle mass upon which to suspend an orthosis.


Custom Fabricated Knee Orthoses A custom fabricated knee immobilizer without joints (L1834)

is covered if criteria 1 and 2 are met:

1. The coverage criteria for the prefabricated orthosis code L1830 are met; and,

2. The general criterion for a custom fabricated orthosis is met.


Custom Fabricated Knee Orthoses A custom fabricated derotation knee orthosis (L1840) is covered

for instability due to internal ligamentous disruption of the knee.

• Requires a covered Group 3 diagnosis code

A custom fabricated knee orthosis with an adjustable flexion and extension joint (L1844, L1846) is covered if:

• The coverage criteria for the prefabricated orthosis codes L1843, L1845, L1851 and L1852 are met; and,

• The general criterion for a custom fabricated orthosis is met.



Custom Fabricated Knee Orthoses A custom fabricated knee orthosis with a modified supracondylar

prosthetic socket (L1860) is covered for a beneficiary who is:

• Ambulatory, and,

• Has knee instability due to genu recurvatum – hyperextended knee.



Miscellaneous Coverage Criteria Heavy duty knee joint codes (L2385, L2395) are covered only for

beneficiaries who weigh more than 300 pounds.

Coverage of a removable soft interface (K0672) is limited to a maximum of two (2) per year beginning one (1) year after the date of service for initial issuance of the orthosis.

• Additional replacement interfaces will be denied as not reasonable and necessary


Miscellaneous Coverage Criteria Concentric Adjustable Torsion-style Mechanisms


L2999 Covered under Brace Benefit: Used to assist knee joint extension in absence of any co-existing joint contracture

E1810 (Custom

Fit)

Covered under DME Benefit: Used to treat contractures; Dynamic adjustable knee extension/flexion device, includes soft interface material

Miscellaneous Coverage Criteria


L2999

Lower extremity orthoses “Not Otherwise Specified” Use only when no other code/definition applies Claim must include:

• Manufacturer’s name • Product name, model name, and model number • Medical necessity for the item • If the item is custom-fabricated, a complete and

clear description of the item including: — What makes the item unique — A breakdown of charges (materials and labor)

Modifiers LT - Left side

RT – Right side

EY – No physician or other licensed health care provider order for this item or service.

GA – Valid Advanced Beneficiary Notice (ABN) was obtained.

GZ - ABN not obtained.

KX – Requirements specified in the medical policy have been met.


Documentation Requirements


Dispensing Order Knee orthoses may be delivered upon receipt of a dispensing

order that contains:

• Description of the item

• Beneficiary's name

• Prescribing physician/practitioner's name

• Date of the order

• Prescribing physician/practitioner's signature (if a written order) or supplier signature (if verbal order)


Orders For the “Date of the order”:

• Verbal orders: use the date the supplier is contacted by the prescribing physician/practitioner

• Written dispensing orders: use the date entered by the prescribing physician/practitioner

For items that are delivered based on a dispensing order, the supplier must obtain a detailed written order (DWO) before submitting a claim.

Someone other than the physician/practitioner may complete the DWO for the Knee Orthoses. However, the prescribing physician/practitioner must review the content and sign and date the document.


Detailed Written Order (DWO) The DWO must contain:

• Beneficiary's name

• Date of the order

• A description of all items, options, accessories or additional features that are separately billed or require an upgraded code. The description can be either a general description (e.g., knee brace), a HCPCS code, a HCPCS code narrative, or a brand name/model number.

• For supplies – list all supplies that are separately billable, and for each include the frequency of use (if applicable), and the quantity dispensed

• Prescribing physician/practitioner's signature (and date if applicable - see above)


Medical Records Detailed documentation in the treating practitioner’s records to

support: • Medical necessity of the item billed. • A focused history and examination of the impacted body part is critical

to establishing medical necessity. • The diagnosis code that is billed on the claim

Templates and forms are subject to corroboration with information in the medical record.

Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.


Orthotist/Prosthetist Records The CPO notes are but part of the whole medical record and are

considered in the context of documentation made by the physician and other healthcare practitioners to provide additional details to demonstrate that the prosthetic arm, leg or orthotic billed to Medicare was reasonable and necessary.

The O&P supplier’s notes are expected to corroborate and provide details consistent with physician/practitioner records.

In the event of a conflict between the prescriber’s notes and the O&P supplier’s record, the DME MAC would likely deny payment.

Similarly, payment may not be provided solely based on O&P documentation, and in the absence of physician/practitioner documentation, the DME MACs may deny payment for the orthotic or prosthetic.


Documentation of Custom Fitted Orthoses Documentation of Substantial Modification:

• Items requiring substantial modification by a qualified practitioner are coded as custom fitted (L1810, L1832, L1843, L1845, L1847).

• Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.


Example of Insufficient Documentation

Billed: L1832 – Knee orthosis, adjustable knee joints (unicentric or polycentric),

positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Claim Denied:

• Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary.

• The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements.


Documentation of Custom Fabricated Orthoses Documentation of Custom Fabrication

• For custom fabricated orthoses (L1834, L1840, L1844, L1846, L1860), there must be detailed documentation in the treating practitioner’s records to support the medical necessity of custom fabricated rather than a prefabricated orthosis as described in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD.

• This information will be corroborated by the functional evaluation in the orthotist or prosthetist’s records. This information must be available upon request.


Documentation Requirements Suppliers must:

• Provide the product that is specified by the prescribing practitioner

• Be sure that the prescribing practitioner’s medical record justifies the need for the type of product (i.e., Prefabricated versus Custom Fabricated)

• Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting

• Have detailed documentation in supplier's records that justifies the code selected

The beneficiary’s condition (diagnosis code) that necessitates the need for the knee orthosis must be included on the claim.


Direct Delivery (Method 1) The proof of delivery document must include:

• Beneficiary’s name

• Delivery address

• A description of the item(s) being delivered. The description can be either a narrative description (e.g., knee brace), a HCPCS code, the long description of a HCPCS code, or a brand name/model number

• Quantity delivered

• Date delivered

• Beneficiary (or designee) signature

Date of Service = The date the beneficiary received the knee orthoses


Shipping Service (Method 2) Supplier Shipping Invoice:

• Beneficiary’s name • Quantity delivered • A description of the item(s) being delivered. • Package identification number

Delivery service tracking slip: • Each beneficiary’s package • Delivery address • Package identification number (tracking number) • Date delivered • Evidence of delivery

Date of Service = Shipping date or date of delivery


Delivery to Nursing Facility on Behalf of a Beneficiary (Method 3) For items directly delivered by the supplier to a nursing facility or

when a delivery service or mail order is used to deliver the item(s) to a nursing facility, the supplier must have:

• Documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and,

• Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.


Knee Orthoses Included in Hospital or SNF Stay Payment for knee orthoses are included in the payment to a

hospital or skilled nursing facility (SNF) if:

1. The orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; and

2. The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., after knee surgery).

A claim must not be submitted to the DME MAC in this situation


Knee Orthoses Included in Hospital or SNF Stay Payment for knee orthoses are also included in the payment to a

hospital or a Part A covered SNF stay if:

1. The orthosis is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to the day of discharge; and

2. The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.

A claim must not be submitted to the DME MAC in this situation


Hospital or SNF Stay Payment for knee orthoses delivered to a beneficiary in a hospital

or a Part A covered SNF stay is eligible for coverage by the DME MAC if:

1. The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and

2. The orthosis is provided to the beneficiary within two days prior to discharge to home; and

3. The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.

The date of service is the date of discharge.


Repairs and Replacement


Repairs A new order is not needed for repairs.

The treating physician must document that the item being repaired continues to be reasonable and necessary.

Either the treating physician or the supplier must document that the repair itself is reasonable and necessary.

The supplier must maintain detailed records describing the need for and nature of all repairs Including: • A detailed explanation justifying the replacement of any component or

part; and • Labor time to restore the item to its functionality.


Billing of Repairs HCPCS L4205: Repair of orthotic device; labor component

per 15 minutes • Claim must include an explanation of what is being repaired.

• May only be billed for time involved with the actual repair of an orthosis or for medically necessary adjustments made more than 90 days after delivery.

• Cannot bill separately when replacing an orthotic component that is coded with a specific L code.

HCPCS L4210: Repair of orthotic device; repair or replace minor parts • Claim must include a description of each item that is billed.


Billing of Repairs Labor allowance for replacing an orthotic component:

All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.


If coded with: Then labor is:

Modifiers: Narrative should state

Specific L code

Included in allowance

Required for replacement part – RT/LT and RB

Describing what was repaired

Miscellaneous L4210

Separately payable

No RT/LT or RB modifier required

Describing item billed

Replacement Identical or similar items may be replaced in cases of:

• Loss or irreparable damage – Use RA modifier on the claim

• Reasonable Useful Lifetime (RUL)

A new order from the treating practitioner is required to reaffirm the medical necessity for the replacement item.

Must maintain documentation for the reason for replacement


Prefabricated Knee Orthoses

Reasonable Useful Lifetime (RUL) One Year Two Years Three Years L1810 L1831 L1836 L1812 L1832 L1843 L1820 L1833 L1845 L1830 L1850 L1851

L1852


Custom-Fabricated Knee Orthoses Three years

Resources


Medicare Minute℠: Telehealth Benefit JA – https://med.noridianmedicare.com/web/jadme/education/dme-on-demand

JB – https://www.cgsmedicare.com/jb/education/Video/vid_telehealth.html

JC – https://www.cgsmedicare.com/jc/education/Video/vid_telehealth.html

JD – https://med.noridianmedicare.com/web/jddme/education/dme-on-demand


https://med.noridianmedicare.com/web/jadme/education/dme-on-demand

https://www.cgsmedicare.com/jb/education/Video/vid_telehealth.html

https://www.cgsmedicare.com/jc/education/Video/vid_telehealth.html

https://med.noridianmedicare.com/web/jddme/education/dme-on-demand

Dear Physician Letter – Knee Orthoses Published May 2018: JA – https://med.noridianmedicare.com/web/jadme/policies/clinician-resources

JB – https://www.cgsmedicare.com/jb/mr/pdf/dear_physician_knee_orthoses.pdf

JC – https://www.cgsmedicare.com/jc/mr/pdf/dear_physician_knee_orthoses.pdf

JD – https://med.noridianmedicare.com/web/jddme/policies/clinician-resources


https://med.noridianmedicare.com/web/jadme/policies/clinician-resources

https://www.cgsmedicare.com/jb/mr/pdf/dear_physician_knee_orthoses.pdf

https://www.cgsmedicare.com/jc/mr/pdf/dear_physician_knee_orthoses.pdf

https://med.noridianmedicare.com/web/jddme/policies/clinician-resources

Jurisdiction A Resources IVR/Contact Center/Reopenings

• 1.866.419.9458

• Monday-Friday, 8:00 a.m. – 5:00 p.m.

Noridian Medicare Portal (NMP)

• https://med.noridianmedicare.com/web/jadme/topics/nmp

Paper Claim Submission: Noridian JA DME Attn: Claim Submission PO Box 6780 Fargo, ND 58108-6780


https://med.noridianmedicare.com/web/jadme/topics/nmp

Jurisdiction B Resources


Interactive Voice Response (IVR) Unit: 1.877.299.7900

Customer Service: 1.866.590.6727 (Monday – Friday, 8:00 a.m. – 5:00 p.m. ET)

Telephone Reopenings: 1.844.240.7490 (Monday – Friday, 8:00 a.m. – 5:00 p.m. ET)

Paper Claim Submission: CGS PO Box 20013 Nashville, TN 37202

Redetermination Requests, Adjustment Requests (Reopenings), EFT Form Submission, and Written Inquiries Address:

Fax: 1.615.660.5976 Mail: CGS PO Box 20007 Nashville, TN 37202

Overpayment Appeals: Fax: 1.615.782.4514 Mail: CGS Overpayment Appeals PO Box 23070 Nashville, TN 37202

Jurisdiction C Resources


Interactive Voice Response (IVR) Unit: 1.866.238.9650

Customer Service: 1.866.270.4909 (Monday – Friday, 7:00 a.m. – 5:00 p.m. CT)

Telephone Reopenings: 1.866.813.7878 (Monday – Friday, 7:00 a.m. – 5:00 p.m. CT)

Paper Claim Submission, Adjustment Requests (Reopenings), EFT Form Submission, and Written Inquiries Address:

CGS PO Box 20010 Nashville, TN 37202

Redetermination Requests: Fax: 1.615.782.4630 Mail: CGS PO Box 20009 Nashville, TN 37202

Overpayment Appeals: Fax: 1.615.664.5907 Mail: CGS Overpayment Appeals PO Box 23917 Nashville, TN 37202

Jurisdiction D Resources IVR/Contact Center/Reopenings

• 1.877.320.0390

• Monday-Friday, 8:00 a.m. – 5:00 p.m.

Noridian Medicare Portal (NMP)

• https://med.noridianmedicare.com/web/jddme/topics/nmp

Paper Claim Submission: Noridian JD DME Attn: Claim Submission PO Box 6727 Fargo, ND 58108-6727


https://med.noridianmedicare.com/web/jddme/topics/nmp

Other Contractor Resources Pricing, Data Analysis and Coding

1.877.735.1326 http://www.dmepdac.com

National Supplier Clearinghouse

1.866.238.9652 http://www.palmettogba.com/nsc

Common Electronic Data Interchange

1.866.311.9184 http://www.ngscedi.com [email protected]


http://www.dmepdac.com/

http://www.palmettogba.com/nsc

http://www.ngscedi.com/

mailto:[email protected]

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Collaborative Knee Orthoses - CGS Medicare · A knee orthosis with a locking knee joint (L1831) or...

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Transcript of Collaborative Knee Orthoses - CGS Medicare · A knee orthosis with a locking knee joint (L1831) or...