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ICD-10-CM T84.420D, Displacement of muscle and tendon graft, subsequent encounter | No Prior Auth

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`T84.420D`, Displacement of muscle and tendon graft, subsequent encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

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.

Supplier must include the treating diagnosis code(s) on the claim line for HCPCS L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, and L1860.

For custom-fabricated orthoses the supplier's records must document the medical necessity of a custom device rather than a prefabricated orthosis, and this documentation must be available upon request.

Suppliers must provide the product specified by the treating practitioner, ensure the practitioner's medical record justifies the product type (prefab versus custom), bill only the HCPCS code that accurately reflects the orthosis and fitting level, and maintain detailed supplier documentation that justifies the code selected.

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.
CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.

4 Active Policies

A52465, Knee Orthoses - Policy Article

A53058, Billing and Coding: Home Health Physical Therapy

A53065, Billing and Coding: Outpatient Physical Therapy

A57311, Billing and Coding: Physical Therapy - Home Health

Related Codes

G57.21(4 policies)G81.92(4 policies)G57.01(4 policies)G57.02(4 policies)G57.22(4 policies)G81.91(4 policies)G04.1(4 policies)G81.93(4 policies)

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