Custom fabricated knee orthoses claims submitted on or after October 1, 2015, may now be subject to review following a new Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) audit that went into effect September 14 regarding those devices.
Local Coverage Determination (LCD) codes that could be affected include: Healthcare Common Procedure Coding System (HCPCS) L-1834, custom fabricated knee immobilizer without joints; L-1840, custom fabricated derotation knee orthosis; L-1844 and L-1846, custom fabricated knee orthosis with an adjustable flexion and extension joint; and L-1860, a custom fabricated knee orthosis with a modified supracondylar prosthetic socket.
The DMEPOS Recovery Auditor, Region 5, will begin reviewing claims documentation to determine if the medical records adequately detail the medical necessity of a custom brace. Claims for custom knee orthoses that do not meet indications of coverage and/or medical necessity will be denied, according to the new audit. The Centers for Medicare & Medicaid Services (CMS) says a custom fabricated orthosis is covered when there is a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis.