HCPCS code L1820: Knee Orthosis, Elastic With Condylar Pads and Joints, With or Without Patellar Control, Prefabricated Item Trimmed and Fitted by an Expert

Ensure proper coding and billing of HCPCS code L1820 by obtaining a list of the code's documentation and billing requirements.

Use Code

## **What is HCPCS code L1820?** HCPCS code L1820 is for a prefabricated knee orthosis (brace) that is "custom-fitted." The "custom-fitted" aspect means it's a prefabricated item that is significantly modified by a qualified professional to fit a specific patient. It features medial and lateral condylar pads, hinges or joints, and optional patellar control. Crucially, the device must be trimmed, bent, molded, assembled, or otherwise customized to fit the patient by a qualified professional upon delivery—not merely self-adjusted. It's typically made of elastic materials like neoprene or spandex. The brace is used to provide support and stability for knee conditions like osteoarthritis, knee ligament injuries, or general instability. to support the knee joint, improve stability, and relieve pain. It's often used for ambulatory patients with knee weakness or deformity.

## **Documentation requirements** Accurate and detailed documentation is crucial for billing L1820 and avoiding denials. Key documentation elements include: - **Standard written order (SWO)**: A prescription from the treating practitioner that includes the patient's name, the date of the order, a description of the item (HCPCS code or a general description), and the practitioner's signature. - **Medical records**: The patient's medical records must support the medical necessity of the brace. This includes: Documentation that the patient is ambulatory. A description of the patient's knee weakness or deformity. A clear statement that the patient requires stabilization. - **Proof of custom-fitting**: Because L1820 is a "custom-fitted" code, the medical record must describe the specific modifications made to the brace to fit the patient. This distinguishes it from an OTS brace.

## **Billing requirements** Billing for HCPCS code L1820 requires adherence to specific guidelines to ensure proper reimbursement. - **Modifiers**: When billing, you will need to use the appropriate modifiers. This often includes: **LT** for the left knee or **RT** for the right knee to specify the side of the body. Other modifiers may be required based on payer policies, such as the **KX** modifier, which indicates that the provider has all the necessary medical documentation to support the claim. - **Off-the-shelf vs. custom-fitted**: It's critical to use the correct code for the type of brace provided. If the brace only requires minimal adjustments, it may need to be billed with an off-the-shelf code (like L1821), which has a different reimbursement rate. The Centers for Medicare & Medicaid Services (CMS) has created new parallel codes to distinguish between custom-fitted and off-the-shelf versions of the same device. - **Supplier requirements**: For Medicare, providers must be an approved Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier to bill for these items.

## **Other relevant codes** Other knee orthosis codes include: - **L1821**: Same L1820 knee brace, but off-the-shelf with minimal fitting - **L1810**: Knee orthosis, elastic with joints, prefabricated, off-the-shelf - **L1830**: Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf - **L1843**: Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, prefabricated, custom-fitted

Frequently asked questions

Use L1820 when the prefabricated knee brace is professionally customized at delivery. Use L1821 when the same model is provided off-the-shelf without professional fitting.

Typically, once per year per knee is allowed for prefabricated orthoses as reasonably useful lifetime; exceeding that may result in denial.

Payer policies vary. While L1820 does not always require prior authorization from Medicare, it's essential to check the specific requirements of the patient's insurance plan before providing the brace to avoid a denial.