HCPCS Code L1843

## **Documentation requirements for L1843** As with any HCPCS code, please make sure you follow all the necessary coding guidelines about coverage, indications, limitations, and/or medical necessity, etc. You must also prepare sufficient documentation, such as the following: - The full name of the patient receiving the knee orthosis - The full name and credentials of the healthcare providers involved in assessing the patient, and the fitting and customization of the knee orthosis - The patient's medical history and any relevant clinical indications and diagnoses to justify the medical necessity of the orthosis - Documentation that supports the customization of the orthosis for the patient as reasonable and necessary, and that customization was done by a certified orthotist or similarly trained professional at the time of delivery - Standard written order (SWO) or written order prior to delivery (WOPD) and proof of delivery - Documentation of face-to-face encounters/evaluations For medical necessity determinations, documentation created by an orthotist or prosthetist is considered part of the patient’s medical record and supports the treating practitioner’s documentation. Keep these O&P notes with the claim file and submit upon request.

## **Billing requirements for L1843** Besides the documentation requirements above, please make sure to take note of or have the following: - You have the relevant diagnosis codes based on the patient's condition - The use of either the RT or LT modifiers. RT for the right knee, LT for the left. If both knees require orthoses, submit two lines with RT and LT separately, each with one unit - Use the KX modifier if all coverage criteria are met. If criteria aren’t met but the beneficiary signs an Advance Beneficiary Notice (ABN), use GA; if no ABN is on file, use GZ - Submit a prior authorization request before delivery. For emergencies, include the ST modifier; otherwise, PA is mandatory - The product must be listed on the PDAC Product Classification List and have a written coding verification review If the KO is provided before an inpatient hospital admission or Part A–covered SNF stay and medical necessity begins during that stay, payment is included in the facility payment—no DME MAC claim should be submitted. If the KO is provided during an inpatient hospital or Part A–covered SNF stay before the day of discharge and used for inpatient treatment/rehab, payment is likewise bundled—do not bill the DME MAC. A KO provided within two (2) days prior to discharge for use after discharge (not needed for inpatient treatment) may be billed to the DME MAC; leave the device in the room for the patient to take home. Again, please familiarize yourself with the relevant LCD-related policy articles/LCD-related standard documentation and other coding guidelines so you can follow correct coding practices.

## **Other similar codes** - **L1844** - Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated - **L1845** - Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise - **L1846** - Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated - **L2861** - Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each