When Can You Bill Orthosis Components Separately?

by  Wyn Staheli, Director of Content - innoviHealth
Jul 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.