When Can You Bill Orthosis Components Separately?
July 9th, 2019 - Wyn Staheli, Director of Research
It can be confusing to determine if a component or a particular feature is considered an integral part of an orthosis or if you can ask for separate payment. Obviously, the best way to determine that is to follow the specific payer's guidelines. The problem is that many payers don't have really good guidelines or policies which make it easy to find that information so sometimes it comes down to trial and error.
The following tables come from Medicare LCD L33318 and include helpful coverage information about add on components for certain DME.
Table heading explanations:
- Base Code: this refers to the main orthosis.
- Add on (Payable): this column refers to other components/features which may be added to the base component which may be considered to be separately payable. However, that is not a guarantee of payment. Other rules such as determination of medical necessity also play a role.
- Add on (not Payable): this is a non-exclusive list of components or features that may be incorporated into the base orthosis, but are not separately payable.
Table 1: Prefabricated Knee Orthosis
|
Base Code
|
Add on (Payable)
|
Add on (not Payable)
|
| L1810 |
none
|
L2397
|
| L1812 |
none |
L2397
|
| L1820 |
none |
L2397
|
| L1830 |
none |
L2397
|
| L1831 |
none |
L2397, L2795
|
| L1832 |
L2397, L2795, L2810
|
L2405, L2415, L2492, L2785
|
| L1833 |
L2397, L2795, L2810
|
L2405, L2415, L2492, L2785
|
| L1836 |
none |
L2397
|
| L1843 |
L2385, L2395, L2397
|
L2405, L2492, L2785
|
| L1845 |
L2385, L2395, L2397, L2795
|
L2405, L2415, L2492, L2785
|
| L1847 |
none |
L2397, L2795
|
| L1848 |
none |
L2397, L2795
|
| L1850 |
L2397 |
L2275 |
| L1851 |
L2385, L2395, L2397
|
L2405, L2492, L2785
|
| L1852 |
L2385, L2395, L2397, L2795
|
L2405, L2415, L2492, L2785
|
Table 2: Custom Fabricated Knee Orthosis
|
Base Code
|
Add on (Payable)
|
Add on (not Payable)
|
| L1834 |
L2795 |
L2397, L2800 |
| L1840 |
L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2755, L2785, L2795 |
L2275, L2800
|
| L1844 |
L2385, L2390, L2395, L2397, L2405, L2492, L2755, L2785 |
none
|
| L1846 |
L2385, L2390, L2395, L2397, L2405, L2415, L2492, L2755, L2785, L2795, L2800 |
none |
| L1860 |
none
|
L2397 |
|
Keep in mind that technically, the above tables only apply to specific DME jurisdictions. However, it can provide some guidance and assistance as you are making coding decisions.
As a final reminder, if you know that an item will be not covered separately, be sure that the patient is informed. For Medicare, that means you will need to use an ABN.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
Artificial Intelligence in Healthcare - A Medical Coder's PerspectiveDecember 26th, 2023 - Aimee WilcoxWe constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities?
Specialization: Your Advantage as a Medical Coding ContractorDecember 22nd, 2023 - Find-A-CodeMedical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)December 19th, 2023 - Aimee WilcoxChronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike AgainDecember 12th, 2023 - Aimee WilcoxAccording to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for AppendicitisNovember 14th, 2023 - Aimee WilcoxWith approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023October 26th, 2023 - Wyn StaheliCOVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M ServicesOctober 11th, 2023 - Wyn Staheli2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
