HCPCS Code L1851

Official Description

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, off-the-shelf

Short Descr	Ko single upright prefab ots
Coverage	Carrier Priced
Pricing Indicator(s)	38 – Supplies And Surgical Dressings - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings)
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	D1F – Prosthetic/Orthotic devices
TOS Code(s)	P – Lump sum purchase of DME, prosthetics, orthotics
Added Date	1/1/2017
APC Status Indicator	Service Paid under Fee Schedule or Payment System other than OPPS
MUE	0
MUE	2
OTS Orthotic	No

KX	Requirements specified in the medical policy have been met
RT	Right side (used to identify procedures performed on the right side of the body)
LT	Left side (used to identify procedures performed on the left side of the body)
KV	Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
GZ	Item or service expected to be denied as not reasonable and necessary
GA	Waiver of liability statement issued as required by payer policy, individual case
CG	Policy criteria applied
ST	Related to trauma or injury
25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
50	Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CQ	Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
GP	Services delivered under an outpatient physical therapy plan of care
GW	Service not related to the hospice patient's terminal condition
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
J5	Off-the-shelf orthotic subject to dmepos competitive bidding program that is furnished as part of a physical therapist or occupational therapist professional service
KT	Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
KY	Dmepos item subject to dmepos competitive bidding program number 5
NU	New equipment
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure