HCPCS L1851: Knee Orthosis, Single Upright, Prefabricated, Off the Shelf

## **Documentation requirements** For L1851 to be considered medically necessary and covered by Medicare, specific documentation requirements must be met. These typically include: ### **Standard written order (SWO)** A complete written order must be on file before the claim is submitted. It must include the beneficiary's name, the order date, a general description of the item (HCPCS code or narrative), and the treating practitioner's name, NPI, and signature. ### **Face-to-face encounter and written order prior to delivery (WOPD)** For L1851, a face-to-face encounter with the treating practitioner is required within six months prior to prescribing the item. A written order must exist prior to delivery of the orthosis. ### **Medical necessity documentation** The patient's medical record from the treating practitioner (physician, PA, NP, or Clinical Nurse Specialist) must clearly document the medical necessity of the brace. ### **Coverage criteria** The orthosis is covered if the beneficiary has had a recent injury or surgical procedure to the knee, OR if the patient is ambulatory and has knee instability due to a specific covered condition. ### **Knee instability** For claims based on knee instability, the documentation must include an objective description of joint laxity (e.g., varus/valgus instability, positive anterior/posterior drawer test result) from the physical examination. Documentation of only pain or a subjective description of instability is generally not sufficient for coverage. ### **ICD-10 codes** The diagnosis code used on the claim must be one that supports medical necessity for this type of brace, as defined in the associated local coverage determination (LCD) Policy Article (often Group 4 codes in the knee orthoses LCD). ### **Proof of Delivery (POD)** Documentation verifying that the patient received the specific brace must be maintained.

## **Billing requirements** To properly bill for HCPCS code L1851, the following guidelines must be considered: - **Prior Authorization (PA)**: L1851 is often on the list of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items that require Prior Authorization for Medicare beneficiaries in specific regions (DME MACs). You must check the current CMS/DME MAC lists. - **Off-the-shelf**: This code specifically denotes an off-the-shelf (OTS) item. This is a brace that requires minimal self-adjustment for fitting and use. - **"Same or Similar" rule**: A knee orthosis is typically subject to a reasonable useful lifetime (RUL) rule, often three years for prefabricated orthoses. A patient generally cannot get another "same or similar" orthosis for the same limb within this RUL period unless the original brace is lost, irreparably damaged, or there is a change in medical condition requiring a new device. - **Coding Verification Review (CVR)**: Some Medicare contractors require that products billed under L1851 must have undergone a CVR by the Pricing, Data Analysis, and Coding (PDAC) contractor and be published on the Product Classification List (PCL).

## **Other relevant codes** - **L1832**: Knee orthosis (KO), 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 - **L1843**: Knee orthosis (KO), 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, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise - **L1845**: Knee orthosis (KO), 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 - **L1852**: Knee orthosis (ko), 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, off-the-shelf - **L2385**: Addition to lower extremity, straight knee joint, heavy duty, each joint