Understanding Knee Brace CPT Codes for Insurance Coverage and Reimbursement

Understanding Knee Brace CPT Codes

Knee injuries and conditions often require the use of knee braces to provide stabilization and support. As a medical device, knee braces may be covered to some extent by health insurance. To obtain coverage and reimbursement, providers need to understand the correct CPT codes to use for knee braces.

What Are CPT Codes?

CPT codes refer to Current Procedural Terminology codes, a medical code set maintained by the American Medical Association. CPT codes are 5 digit numeric codes that represent medical procedures and services provided by healthcare professionals. They provide a way to document and categorize medical, surgical, and diagnostic services to facilitate billing and reimbursement from insurance companies and Medicare/Medicaid.

Common Knee Brace CPT Codes

The most common CPT knee brace codes include:

• L1810 - Knee orthosis, elastic with joints, prefabricated
• L1820 - Knee orthosis, elastic with condylar pads and joints, prefabricated
• L1830 - Knee orthosis, immobilizer, canvas longitudinal, prefabricated
• L1831 - Knee orthosis, locking knee joint, positional orthosis, prefabricated
• L1832 - Knee orthosis, adjustable knee joints, rigid support, prefabricated
• L1833 - Knee orthosis, adjustable knee joints, elastic support, prefabricated
• L1843 - Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control
• L1844 - Knee orthosis, single upright, thigh and calf with adjustable flexion and extension joint, custom fabricated

Considerations for Selecting the Correct Code

Choosing the right CPT code for a knee brace depends on several factors:

• Is it prefabricated (off-the-shelf) or custom-fabricated?
• What materials is it made of? (e.g. elastic, canvas, metal/rigid plastic)
• Does it have adjustable joints or range of motion control?
• Does it have condylar pads?
• Does it provide medial-lateral and rotation control?
• What area does it cover? (e.g. thigh and calf vs just knee joint)

Providers should select the code that most accurately describes the specific knee brace that has been provided.

Billing and Reimbursement for Knee Braces

The reimbursement amount for knee brace CPT codes varies depending on geographical location and insurance plans. On average:

• L1810 reimburses approximately $65
• L1820 reimburses approximately $75
• Other knee brace codes reimburse between $90 to $350

Some things that impact reimbursement levels include:

• Medicare Capped Rental - Medicare treats knee braces as capped rental items, only making recurring payments for a maximum of 13 months for any single item.
• Medical Necessity - Insurers will often require confirmation of medical necessity through providing medical records, imaging reports, and/or a letter of medical necessity.
• In-Network vs Out-of-Network - Reimbursements are usually higher for providers that are in a payer's network.
• Deductibles and Copays - Depending on the insurance plan, patients may be responsible for 100% of costs until reaching their deductible, after which copays and coverage often still apply.

Different Types of Knee Braces

There are several different types of knee braces used for a variety of knee-related conditions. The main types include:

Prophylactic Knee Braces

Prophylactic braces provide medial and lateral support to help protect the knee from contact injuries in sports or high risk occupations. They integrate hinged polycentric joints to avoid limiting range of motion.

Rehabilitative Knee Braces

Rehabilitative braces immobilize and stabilize the knee immediately following injury, surgery or severe trauma to promote proper healing. They restrict range of motion to protect the joint.

Functional Knee Braces

Functional braces offer medial and lateral stability while still allowing for athletic performance. They typically incorporate rigid framing with a flexible dynamic joint system and are often used to prevent re-injury after ligament tears.

How Knee Braces Help

There are several ways that knee braces can help individuals with various knee conditions:

Pain Relief

Many types of knee braces redistribute pressure and loading force within the knee joint which helps relieve pain from arthritis, cartilage tears, ligament strains and other conditions. Braces also limit excessive movements that contribute to pain and inflammation.

Stability

Knee braces with rigid supports and adjustable joints improve stability for those recovering from ligament tears, fractures, sprains or surgery. They allow controlled movement while protecting vulnerable structures.

Injury Prevention

Prophylactic knee braces can help athletes, military personnel and occupational workers avoid devastating contact knee injuries. They shield the joint from traumatic impacts and collisions.

Healing Promotion

Wearing an appropriate knee brace following surgery or injury promotes proper healing by immobilizing and protecting the affected structures. Controlled compression and restricted range of motion avoid re-injury.

Increased Function

For those with chronic conditions like arthritis or prior injuries, knee braces allow them to maintain an active lifestyle with improved stability and pain management during daily activities and recreation.

When to Consider a Knee Brace

The most common reasons to use a knee brace include:

• Torn knee ligaments (ACL, PCL, MCL, LCL)
• Cartilage tears (meniscus injuries)
• Knee fracture recovery
• Rehabilitation post-knee surgery
• Moderate to severe knee arthritis
• Patellofemoral pain syndrome
• Iliotibial band syndrome (ITBS)
• Prevention of sports and occupational knee injuries

Consulting an orthopedic specialist or sports medicine physician can help determine if wearing a knee brace would be beneficial.

Risks and Downsides of Knee Braces

While often helpful, it’s important to keep the following risks and downsides of knee braces in mind:

• Skin irritation, blisters or rashes
• Restricted blood flow
• Decreased proprioception
• Muscle weakness or atrophy
• Dependence on the support
• Added stress to other joints
• False sense of security with injury risks

Wearing a brace too much or for too long can sometimes do more harm than good. Speak to your doctor about using proper brace sizing and fit, gradual weaning from the device, and supplemental rehab to strengthen muscles.

Knee Brace CPT Codes and Insurance Coverage

The knee brace CPT codes help streamline billing, reimbursement and insurance coverage determinations. However, coverage and payment still varies between insurance companies and Medicare/Medicaid. Speak with your provider about your options to receive the knee support you need.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.