T84.85XA — Stenosis due to internal orthopedic prosthetic devices, implants and grafts, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For knee orthoses with adjustable knee joints or prefabricated Swedish type (HCPCS L1832, L1833, L1850) the medical record must document a physical examination of the affected knee(s) including the joint laxity test(s) performed and a description of exam findings that support objective joint laxity.
- For single or double upright, adjustable flexion/extension knee orthoses with medial-lateral and rotation control (HCPCS L1843, L1844, L1845, L1846, L1851, L1852) used for ambulatory beneficiaries with knee instability, medical records must document ambulatory status and a physical exam of the affected knee(s) including joint laxity test(s) performed and description of findings supporting objective joint laxity.
- For the same single/double upright orthoses (L1843, L1844, L1845, L1846, L1851, L1852) when used to manage pain affecting mobility/function due to medial or lateral tibiofemoral osteoarthritis, records must include ambulatory status; pain symptoms or mobility/functional reduction; physical exam of the affected knee(s); an imaging report describing arthritic changes consistent with medial/lateral tibiofemoral osteoarthritis; and the beneficiary's willingness to use the orthosis.
Key Coverage Criteria
- A knee orthosis is covered when it is a rigid or semi-rigid device used to support a weak or deformed knee or to restrict or eliminate motion in a diseased or injured knee and the device meets the reasonable and necessary requirements of the related Local Coverage Determination and all statutory/regulatory requirements.
- Both off-the-shelf (OTS) and custom-fit knee orthoses are treated as prefabricated braces for coding and may be covered provided the coding accurately reflects whether only minimal self-adjustment was required at final fitting per 42 CFR §414.402.
- If the orthosis is provided prior to an inpatient hospital admission or Part A SNF stay and the medical necessity begins during that inpatient stay, payment is included in the hospital or SNF payment (do not submit claim to the DME MAC).
- An orthosis provided within two days prior to discharge and not needed for inpatient treatment but intended for home use is eligible for DME MAC coverage if medically necessary after discharge.
- Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
- Beneficiary is under the care of a physician.
4 Active Policies
A52465 — Knee Orthoses - Policy Article
J19
CIGNA-0509 — Intraoperative Monitoring - (0509)
A57311 — Billing and Coding: Physical Therapy - Home Health
L33942 — Physical Therapy - Home Health
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