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When Can You Bill Orthosis Components Separately?

By:  Wyn Staheli, Director of Research
Published:  July 9th, 2019

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.


References:

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