KNEE BRACES 6 - AAPC

MEDICAL POLICY

POLICY TITLE KNEE BRACES

POLICY NUMBER MP- 6.012

Page 1 [Note: Final page is signature page and is kept on file, but not issued with Policy.]

Original Issue Date (Created): July 1, 2002

Most Recent Review Date (Revised): November 26, 2013

Effective Date: February 1, 2014

I. POLICY

Custom-made unloader knee braces may be considered medically necessary in the

treatment of patients with painful osteoarthritis involving the medial compartment of the

knee.

Off-the-shelf (custom-fitted) functional knee braces may be considered medically

necessary in patients with knee instability due to injury (including patients who have had

surgery for the injury) or in patients with painful osteoarthritis of the medial compartment

of the knee.

Custom-made functional knee braces are considered not medically necessary. However,

the medical necessity of a custom-made knee brace may be given individual consideration

in any of the following situations:

Patients with abnormal limb contour;

Knee deformity; or

Large knee size.

Prophylactic knee braces are considered not medically necessary.

II. PRODUCT VARIATIONS

[N] = No product variation, policy applies as stated

[Y] = Standard product coverage varies from application of this policy, see below

[N] Capital Cares 4 Kids [N] Indemnity

[N] PPO [N] SpecialCare

[N] HMO [N] POS

[Y] SeniorBlue HMO* [N] FEP PPO

[Y] SeniorBlue PPO*

*For components, which describe features that can be physically incorporated in the specified

prefabricated base orthoses or additional indications for custom fabricated knee orthoses, refer to

Durable Medical Equipment Medicare Administrative Contractor (DME MAC A) Local Coverage

Determination (LCD L27263) Knee Orthoses.

http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L27263_2012-07-01_PA_2012-07.pdf

MEDICAL POLICY




III. DESCRIPTION/BACKGROUND

Knee braces may be custom made or available off-the-shelf in a variety of sizes. Knee

braces may be intended for rehabilitation, to reduce pain, or to prevent injury in either

stable or unstable knees.

Knee braces typically consist of 3 components: a superstructure (usually a rigid shell), a

hinge, and a strap system. The superstructure extends proximally and distally to a hinge

centered around the knee axis of motion. The strapping system secures the brace to the

limb. Knee braces can be subdivided into 4categories that are based on their intended use:

Prophylactic braces are those that attempt to prevent or reduce the severity of knee

ligament injuries. These braces are primarily designed to prevent injuries to the

medial collateral ligament, which is the area of the most common athletic knee

injuries.

Rehabilitation braces are designed to allow protected motion of injured knees that

have been treated operatively or non-operatively. These braces allow for controlled

joint motion and typically consist of hinges that can be locked into place to limit

range of motion. Rehabilitation braces are commonly used for 6 to 12 weeks after

an injury. Rehabilitation braces are usually purchased off-the-shelf and not custom-

made. Functional braces are designed to assist or provide stability for unstable

knees during activities of daily living (ADL) or sports and may be either off-the-

shelf or custom made. Derotation braces are typically used after injuries to

ligaments and have medial and lateral bars with varying hinge and strap designs.

These derotation braces are designed to permit significant motion and speed; in

many instances, the braces are worn only during elective activities, such as sports.

Braces made of graphite, titanium, or other lightweight materials are specifically

designed for high-performance sports allowing them to be worn during elective

high performance sports activities. Functional knee braces have also be used in

patients with osteoarthritis to help decrease the weight on painful joints.

Unloader knee braces are specifically designed to reduce the pain and disability

associated with osteoarthritis of the medial compartment of the knee by bracing the

knee in the valgus position to unload the compressive forces on the medial

compartment.

IV. RATIONALE

Osteoarthritis

In 1999, Kirkley and colleagues reported on a controlled trial that randomly assigned 119

patients with medial compartment osteoarthritis to receive standard medical management,

medical management plus a polychloroprene (Neoprene) sleeve, or medical management

MEDICAL POLICY




plus an unloader knee brace. (4) Compared to the control group, the unloader knee brace

group was associated with a significant improvement in quality of life and function. In

comparing the unloader knee brace with the Neoprene sleeve, there was a significant

difference in functional outcomes favoring the unloader knee but no significant difference

in terms of quality-of-life measures.

In a 2005 Cochrane review of braces and orthoses for treating osteoarthritis of the knee,

Brouwer et al. concluded that there was limited evidence in favor of an unloader knee

brace. (5) In 2006, Brouwer and colleagues reported a randomized multicenter trial of 117

patients that compared off-the-shelf unloading braces and conservative therapy with

conservative therapy alone for unicompartmental (valgus or varus) osteoarthritis of the

knee. (6) The addition of a brace resulted in a slight increase in reported walking distances

at 3, 6, and 12 months (effect size of 0.4), with trends for improvement in subjective pain (-

0.63 on a 10-point visual analogue scale [VAS]) and knee function (3 points on a 100-point

Hospital for Special Surgery score). Quality of life did not differ between the two groups.

The authors noted that adherence to the brace was low, with 16 of 60 patients (27%)

discontinuing by 3 months and another 9 (15%) stopping treatment by 12 months. Patient-

reported reasons for discontinuing use of the unloading brace were lack of benefit and

adverse effects (i.e., skin irritation, bad fit).

Another study from 2006 compared custom-made and off-the-shelf bracing for varus

gonarthrosis. (7) Ten patients wore each type of brace for 4-5 weeks (approximately 9

hours per day) in a randomized order. Pain scores were reduced from 197 mm (500 mm

maximum) to 71 mm with the custom brace and 120 mm with the off-the-shelf brace.

Stiffness was reduced from 91 mm (200 mm maximum) to 36 mm with the custom brace

and 63 mm with the off-the-shelf brace. Function was improved from 664 mm (1,700 mm

maximum) to 248 mm with the custom brace, whereas the off-the-shelf brace did not

significantly affect function. Kinematic analysis showed a reduction in peak knee

adduction moments during gait and stair-stepping and reduced varus angulation by 1.5

degrees, compared with baseline with the custom brace. The off-the-shelf brace did not

reduce the varus angle.

A French clinical practice guideline committee evaluated evidence on the use of braces in

knee osteoarthritis in 2009. (8) The review found mainly low-quality evidence in support of

valgus knee braces for symptomatic medial femoro-tibial osteoarthritis with short- and

mid-term reduction of pain and disability. Adverse effects included venous

thromboembolic events. No additional controlled trials were identified in a 2010 review of

bracing in the management of knee osteoarthritis. (9)

A 2010 study compared use of insoles or off-the-shelf braces for medial knee osteoarthritis

in a randomized trial of 91 patients with medial compartmental knee osteoarthritis. (10)

Pain severity, measured by a 10-point VAS, improved by 0.9 in the insole group and 1.0

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for the brace group in intent-to-treat analysis. Function on the Western Ontario and

McMaster Universities Osteoarthritis Index (WOMAC) improved by 4.2 and 4.0 points,

respectively, out of 100. There was no significant effect on the hip-knee-ankle angle for

either device. Compliance was 45% for the brace group, with a mean wearing time of 39

hours (standard deviation [SD] 32 hours). After 6 months of use, neither insoles nor off-

the-shelf braces resulted in clinically significant changes in varus angle, pain, or function.

In 2011, Hunter et al. reported a randomized trial of patellofemoral bracing for the

treatment of patellofemoral osteoarthritis. (11) Eighty subjects completed 6 weeks with a

BioSkin Q Brace with the patellar realigning strap applied and 6 weeks with the realigning

strap removed. There was a 6-week interval between the 2 conditions, and the order of

treatment was randomized. They found no effect of treatment on VAS knee pain and no

significant difference between the groups for WOMAC pain, function, or stiffness

outcomes.

Ligamentous Instability of the Knee

Soma and colleagues compared the performance of custom-made and off-the-shelf

functional knee braces from 4 manufacturers in 2004. (12) As a group, the custom-made

knee braces restrained anterior displacement better than the off-the-shelf models by a mean

difference of 0.84 mm. The clinical significance of this minimal but statistically significant

difference is questionable.

A 2007 systematic review of 12 randomized controlled trials (RCTs) of bracing for

rehabilitation following anterior cruciate ligament (ACL) reconstruction “found no

evidence supporting the routine use of functional or rehabilitative bracing in a patient with

a reconstructed ACL. In particular, no study demonstrated a clinically important finding of

improved range of motion, decreased pain, improved graft stability, or decreased

complications and reinjuries.” (13)

In 2008, Birmingham and colleagues reported an RCT that compared the use of an off-the-

shelf functional knee brace or Neoprene sleeve beginning 6 weeks after ACL

reconstruction. (14) Of 150 patients randomly assigned to a brace or sleeve after surgery,

127 (85%) completed 24-month follow-up. Compliance was similar for the 2 groups, and 3

patients from each group had graft failures and revision surgeries. Confidence in the knee

was rated higher for the brace (70 vs. 55, respectively out of 100), as was the rating of help

in returning to sport (66 vs. 53, respectively). No other outcome measures differed between

the groups, including the ACL-quality-of-life questionnaire, highest activity level,

satisfaction with the brace/sleeve, side-to-side laxity, or functional tests. As this report

described evaluators as blinded to the patient’s group allocation, it does not appear that the

patients were wearing the brace or sleeve at the time of functional testing.

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Patellofemoral Pain Syndrome

In 2008, Warden et al. reported a meta-analysis of 16 randomized or quasi-randomized

studies assessing patellar taping or bracing effects on chronic knee pain. (15) Thirteen trials

investigated taping or bracing for anterior knee pain, and 3 investigated taping for

osteoarthritis. The authors concluded there was limited evidence to demonstrate the

efficacy of patellar bracing. They reported high heterogeneity between study outcomes and

significant publication bias in the studies.

Summary

Evidence of efficacy is limited for off-the-shelf bracing for osteoarthritis, ligamentous

instability, or patellofemoral pain.

Practice Guidelines and Position Statements

The American Academy of Orthopaedic Surgeons (AAOS) provided a 2009 clinical

practice guideline on the nonarthroplasty treatment of osteoarthritis of the knee. (16) The

AAOS was unable to make a recommendation for or against the use of a brace with a

varus- or valgus-directing force for patients with medial or lateral unicompartmental

osteoarthritis of the knee, based on limited evidence for the effectiveness of knee braces.

(4,6)

V. DEFINITIONS

BASIC ACTIVITIES OF DAILY LIVING include and are limited to walking in the home,

eating, bathing, dressing, and homemaking.

CUSTOM-MADE BRACE describes a brace that is made according to precise measurements

or molds/casts of an individual patient. Thus, this type of a brace can only be worn by the

individual patient for whom it was customized. A custom-fabricated or molded-to-patient-

model is often referred to as a customized brace.

OFF-THE-SHELF BRACE refers to a brace that is obtained from a selection of readily

available braces. Most often, simple adjustments are made to ensure proper fit.

VI. BENEFIT VARIATIONS

The existence of this medical policy does not mean that this service is a covered benefit

under the member's contract. Benefit determinations should be based in all cases on the

applicable contract language. Medical policies do not constitute a description of benefits.

A member’s individual or group customer benefits govern which services are covered,

MEDICAL POLICY




which are excluded, and which are subject to benefit limits and which require

preauthorization. Members and providers should consult the member’s benefit information

or contact Capital for benefit information.

VII. DISCLAIMER

Capital’s medical policies are developed to assist in administering a member’s benefits, do not

constitute medical advice and are subject to change. Treating providers are solely responsible for

medical advice and treatment of members. Members should discuss any medical policy related to

their coverage or condition with their provider and consult their benefit information to determine if

the service is covered. If there is a discrepancy between this medical policy and a member’s benefit

information, the benefit information will govern. Capital considers the information contained in

this medical policy to be proprietary and it may only be disseminated as permitted by law.

VIII. REFERENCES

1. Liu SH, Mirzayan R. Current review. Functional knee bracing. Clin Orthop Relat Res

1995; (317):273-81.

2. Beynnon BD, Pope MH, Wertheimer CM et al. The effect of functional knee-braces on

strain on the anterior cruciate ligament in vivo. J Bone Joint Surg Am 1992; 74(9):1298-

312.

3. Matsuno H, Kadowaki KM, Tsuji H. Generation II knee bracing for severe medial

compartment osteoarthritis of the knee. Arch Phys Med Rehabil 1997; 78(7):745-9.

4. Kirkley A, Webster-Bogaert S, Litchfield R et al. The effect of bracing on varus

gonarthrosis. J Bone Joint Surg Am 1999; 81(4):539-48.

5. Brouwer RW, Jakma TS, Verhagen AP et al. Braces and orthoses for treating

osteoarthritis of the knee. Cochrane Database Syst Rev 2005; (1):CD004020.

6. Brouwer RW, van Raaij TM, Verhaar JA et al. Brace treatment for osteoarthritis of the

knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage 2006;

14(8):777-83.

7. Draganich L, Reider B, Rimington T et al. The effectiveness of self-adjustable custom and

off-the-shelf bracing in the treatment of varus gonarthrosis. J Bone Joint Surg Am 2006;

88(12):2645-52.

8. Beaudreuil J, Bendaya S, Faucher M et al. Clinical practice guidelines for rest orthosis,

knee sleeves, and unloading knee braces in knee osteoarthritis. Joint Bone Spine 2009;

76(6):629-36.

9. Rannou F, Poiraudeau S, Beaudreuil J. Role of bracing in the management of knee

osteoarthritis. Curr Opin Rheumatol 2010; 22(2):218-22.

10. van Raaij TM, Reijman M, Brouwer RW et al. Medial Knee Osteoarthritis Treated by

Insoles or Braces: A Randomized Trial. Clin Orthop Relat Res 2010; 468(7):1926-32.

11. Hunter DJ, Harvey W, Gross KD et al. A randomized trial of patellofemoral bracing for

treatment of patellofemoral osteoarthritis. Osteoarthritis Cartilage 2011 (in press).

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12. Soma CA, Cawley PW, Liu S et al. Custom-fit versus premanufactured braces.

Orthopedics 2004; 27(3):307-10.

13. Wright RW, Fetzer GB. Bracing after ACL reconstruction: a systematic review. Clin

Orthop Relat Res 2007; 455:162-8.

14. Birmingham TB, Bryant DM, Giffin JR et al. A randomized controlled trial comparing

the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate

ligament reconstruction. Am J Sports Med 2008; 36(4):648-55.

15. Warden SJ, Hinman RS, Watson MA, Jr. et al. Patellar taping and bracing for the

treatment of chronic knee pain: a systematic review and meta-analysis. Arthritis Rheum

2008; 59(1):73-83.

16. Richmond J, Hunter D, Irrgang J et al. Treatment of osteoarthritis of the knee

(nonarthroplasty). J Am Acad Orthop Surg 2009; 17(9):591-600.

Other:

Durable Medical Equipment Medicare Administrative Contractor (DME MAC A) Local

Coverage Determination (LCD) L27263. Knee Orthoses. Effective

02/04/11.[Website]:

http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L27263_

2012-07-01_PA_2012-07.pdf Accessed September 16, 2013.

IX. CODING INFORMATION

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The

identification of a code in this section does not denote coverage as coverage is determined

by the terms of member benefit information. In addition, not all covered services are

eligible for separate reimbursement.

Covered when medically necessary:

HCPCS

Code Description

K0672 ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL

COMPONENTS, REPLACEMENT ONLY, EACH

L1810 KO, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1820 KO ELAST W/CONDYLR PADS&JNT PRFAB INCL FIT&ADJ

L1830 KO, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, INCLUDES FITTING AND

ADJUSTMENT

http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L27263_2012-07-01_PA_2012-07.pdf

MEDICAL POLICY




HCPCS

Code Description

L1831 KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED,

INCLUDES FITTING AND ADJUSTMENT

L1832 KO ADJ KNEE JNT UNICENT/POLYCNT RIGD PREFAB

L1834 KO, WITHOUT KNEE JOINT, RIGID, CUSTOM FABRICATED

L1836 KNEE ORTHOS RIGD NO JNT W/INTRFCE

L1840 KO, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM

FABRICATED

L1843 KO 1 UPRT THI&CALF ADJ UNICNT/POLYCNT PREFAB

L1844 KO 1 UPRT THI&CALF ADJ UNICNT/POLYCNT CSTM FAB

L1845 KO DBL UPRT THI&CALF ADJ UNICNT/POLYCNT PREFAB

L1846 KO DBL UPRT THI&CALF ADJ UNICNT/POLYCNT CSTM FAB

L1847 KO DBL UPRT W/ADJ JNT-INFLAT AIR SUPP CHMB PRFAB

L1850 KO, SWEDISH TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1860 KO, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM FABRICATED

(SK)

L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC

MODIFICATION, PADDED/LINED

L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT

L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT

L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT

L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE

L2405 ADDITION TO KNEE JOINT DROP LOCK EACH

L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM (BAIL, CABLE, OR

EQUAL), ANY MATERIAL, EACH JOINT

L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION,

EACH JOINT

L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE

EXTENSION, EACH JOINT

L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING

L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR

L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NONCORROSIVE FINISH, PER BAR

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HCPCS

Code Description

L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH

L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP

L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD

L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC,

BELOW KNEE SECTION

L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC,

ABOVE KNEE SECTION

L4002 REPACLEMENT STRAP, ANY ORTHOTIC, INCLUDES ALL COMPONENTS, ANY LENGTH,

ANY TYPE

ICD-9-CM

Diagnosis

Code*

Description

715.16 PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG

715.26 SECONDARY LOCALIZED OSTEOARTHROSIS, LOWER LEG

715.36 LOCALIZED OSTEOARTHROSIS NOT SPECIFIED WHETHER PRIMARY OR SECONDARY,

LOWER LEG

717.0 -

717.9 INTERNAL DERANGEMENT OF KNEE

718.86 OTHER JOINT DERANGEMENT, NOT ELSEWHERE CLASSIFIED, LOWER LEG

727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON

736.41-

736.42 GENU VALGUM OR VARUM (ACQUIRED)

736.5 GENU RECURVATUM (ACQUIRED)

736.6 OTHER ACQUIRED DEFORMITIES OF KNEE

822.0 CLOSED FRACTURE OF PATELLA

822.1 OPEN FRACTURE OF PATELLA

836.0-

836.69 DISLOCATION OF KNEE

844.0 -

844.9 SPRAINS AND STRAINS OF KNEE AND LEG

V58.78 AFTERCARE FOLLOWING SURGERY OF THE MUSCULOSKELETAL SYSTEM, NEC

*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.

MEDICAL POLICY




The following ICD-10 diagnosis codes will be effective October 1, 2014

ICD-10-CM

Diagnosis

Code*

Description

M17.0 Bilateral primary osteoarthritis of knee

M17.10 Unilateral primary osteoarthritis, unspecified knee

M17.11 Unilateral primary osteoarthritis, right knee

M17.12 Unilateral primary osteoarthritis, left knee

M17.2 Bilateral post-traumatic osteoarthritis of knee

M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee

M17.31 Unilateral post-traumatic osteoarthritis, right knee

M17.32 Unilateral post-traumatic osteoarthritis, left knee

M17.4 Other bilateral secondary osteoarthritis of knee

M17.5 Other unilateral secondary osteoarthritis of knee

M17.9 Osteoarthritis of knee, unspecified

M21.061 Valgus deformity, not elsewhere classified, right knee

M21.062 Valgus deformity, not elsewhere classified, left knee

M21.069 Valgus deformity, not elsewhere classified, unspecified knee

M21.161 Varus deformity, not elsewhere classified, right knee

M21.162 Varus deformity, not elsewhere classified, left knee

M21.169 Varus deformity, not elsewhere classified, unspecified knee

M21.861 Other specified acquired deformities of right lower leg

M21.862 Other specified acquired deformities of left lower leg

M21.869 Other specified acquired deformities of unspecified lower leg

M22.2x1 Patellofemoral disorders, right knee

M22.2x2 Patellofemoral disorders, left knee

M22.2x9 Patellofemoral disorders, unspecified knee

M22.3x1 Other derangements of patella, right knee

M22.3x2 Other derangements of patella, left knee

M22.3x9 Other derangements of patella, unspecified knee

M22.40 Chondromalacia patellae, unspecified knee

M22.41 Chondromalacia patellae, right knee

M22.42 Chondromalacia patellae, left knee

M22.8x1 Other disorders of patella, right knee

M22.8x2 Other disorders of patella, left knee

M22.8x9 Other disorders of patella, unspecified knee

M22.90 Unspecified disorder of patella, unspecified knee

M22.91 Unspecified disorder of patella, right knee

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ICD-10-CM

Diagnosis

Code*

Description

M22.92 Unspecified disorder of patella, left knee

M23.000 Cystic meniscus, unspecified lateral meniscus, right knee

M23.001 Cystic meniscus, unspecified lateral meniscus, left knee

M23.002 Cystic meniscus, unspecified lateral meniscus, unspecified knee

M23.003 Cystic meniscus, unspecified medial meniscus, right knee

M23.004 Cystic meniscus, unspecified medial meniscus, left knee

M23.005 Cystic meniscus, unspecified medial meniscus, unspecified knee

M23.006 Cystic meniscus, unspecified meniscus, right knee

M23.007 Cystic meniscus, unspecified meniscus, left knee

M23.009 Cystic meniscus, unspecified meniscus, unspecified knee

M23.011 Cystic meniscus, anterior horn of medial meniscus, right knee

M23.012 Cystic meniscus, anterior horn of medial meniscus, left knee

M23.019 Cystic meniscus, anterior horn of medial meniscus, unspecified knee

M23.021 Cystic meniscus, posterior horn of medial meniscus, right knee

M23.022 Cystic meniscus, posterior horn of medial meniscus, left knee

M23.029 Cystic meniscus, posterior horn of medial meniscus, unspecified knee

M23.031 Cystic meniscus, other medial meniscus, right knee

M23.032 Cystic meniscus, other medial meniscus, left knee

M23.039 Cystic meniscus, other medial meniscus, unspecified knee

M23.041 Cystic meniscus, anterior horn of lateral meniscus, right knee

M23.042 Cystic meniscus, anterior horn of lateral meniscus, left knee

M23.049 Cystic meniscus, anterior horn of lateral meniscus, unspecified knee

M23.051 Cystic meniscus, posterior horn of lateral meniscus, right knee

M23.052 Cystic meniscus, posterior horn of lateral meniscus, left knee

M23.059 Cystic meniscus, posterior horn of lateral meniscus, unspecified knee

M23.061 Cystic meniscus, other lateral meniscus, right knee

M23.062 Cystic meniscus, other lateral meniscus, left knee

M23.069 Cystic meniscus, other lateral meniscus, unspecified knee

M23.200 Derangement of unspecified lateral meniscus due to old tear or injury, right knee

M23.201 Derangement of unspecified lateral meniscus due to old tear or injury, left knee

M23.202 Derangement of unspecified lateral meniscus due to old tear or injury, unspecified knee

M23.203 Derangement of unspecified medial meniscus due to old tear or injury, right knee

M23.204 Derangement of unspecified medial meniscus due to old tear or injury, left knee

M23.205 Derangement of unspecified medial meniscus due to old tear or injury, unspecified knee

M23.206 Derangement of unspecified meniscus due to old tear or injury, right knee

M23.207 Derangement of unspecified meniscus due to old tear or injury, left knee

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ICD-10-CM

Diagnosis

Code*

Description

M23.209 Derangement of unspecified meniscus due to old tear or injury, unspecified knee

M23.211 Derangement of anterior horn of medial meniscus due to old tear or injury, right knee

M23.212 Derangement of anterior horn of medial meniscus due to old tear or injury, left knee

M23.219 Derangement of anterior horn of medial meniscus due to old tear or injury, unspecified knee

M23.221 Derangement of posterior horn of medial meniscus due to old tear or injury, right knee

M23.222 Derangement of posterior horn of medial meniscus due to old tear or injury, left knee

M23.229 Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified knee

M23.231 Derangement of other medial meniscus due to old tear or injury, right knee

M23.232 Derangement of other medial meniscus due to old tear or injury, left knee

M23.239 Derangement of other medial meniscus due to old tear or injury, unspecified knee

M23.241 Derangement of anterior horn of lateral meniscus due to old tear or injury, right knee

M23.242 Derangement of anterior horn of lateral meniscus due to old tear or injury, left knee

M23.249 Derangement of anterior horn of lateral meniscus due to old tear or injury, unspecified knee

M23.251 Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee

M23.252 Derangement of posterior horn of lateral meniscus due to old tear or injury, left knee

M23.259 Derangement of posterior horn of lateral meniscus due to old tear or injury, unspecified knee

M23.261 Derangement of other lateral meniscus due to old tear or injury, right knee

M23.262 Derangement of other lateral meniscus due to old tear or injury, left knee

M23.269 Derangement of other lateral meniscus due to old tear or injury, unspecified knee

M23.300 Other meniscus derangements, unspecified lateral meniscus, right knee

M23.301 Other meniscus derangements, unspecified lateral meniscus, left knee

M23.302 Other meniscus derangements, unspecified lateral meniscus, unspecified knee

M23.303 Other meniscus derangements, unspecified medial meniscus, right knee

M23.304 Other meniscus derangements, unspecified medial meniscus, left knee

M23.305 Other meniscus derangements, unspecified medial meniscus, unspecified knee

M23.306 Other meniscus derangements, unspecified meniscus, right knee

M23.307 Other meniscus derangements, unspecified meniscus, left knee

M23.309 Other meniscus derangements, unspecified meniscus, unspecified knee

M23.311 Other meniscus derangements, anterior horn of medial meniscus, right knee

M23.312 Other meniscus derangements, anterior horn of medial meniscus, left knee

M23.319 Other meniscus derangements, anterior horn of medial meniscus, unspecified knee

M23.321 Other meniscus derangements, posterior horn of medial meniscus, right knee

M23.322 Other meniscus derangements, posterior horn of medial meniscus, left knee

M23.329 Other meniscus derangements, posterior horn of medial meniscus, unspecified knee

M23.331 Other meniscus derangements, other medial meniscus, right knee

M23.332 Other meniscus derangements, other medial meniscus, left knee

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

M23.339 Other meniscus derangements, other medial meniscus, unspecified knee

M23.341 Other meniscus derangements, anterior horn of lateral meniscus, right knee

M23.342 Other meniscus derangements, anterior horn of lateral meniscus, left knee

M23.349 Other meniscus derangements, anterior horn of lateral meniscus, unspecified knee

M23.351 Other meniscus derangements, posterior horn of lateral meniscus, right knee

M23.352 Other meniscus derangements, posterior horn of lateral meniscus, left knee

M23.359 Other meniscus derangements, posterior horn of lateral meniscus, unspecified knee

M23.361 Other meniscus derangements, other lateral meniscus, right knee

M23.362 Other meniscus derangements, other lateral meniscus, left knee

M23.369 Other meniscus derangements, other lateral meniscus, unspecified knee

M23.40 Loose body in knee, unspecified knee

M23.41 Loose body in knee, right knee

M23.42 Loose body in knee, left knee

M23.50 Chronic instability of knee, unspecified knee

M23.51 Chronic instability of knee, right knee

M23.52 Chronic instability of knee, left knee

M23.601 Other spontaneous disruption of unspecified ligament of right knee

M23.602 Other spontaneous disruption of unspecified ligament of left knee

M23.609 Other spontaneous disruption of unspecified ligament of unspecified knee

M23.611 Other spontaneous disruption of anterior cruciate ligament of right knee

M23.612 Other spontaneous disruption of anterior cruciate ligament of left knee

M23.619 Other spontaneous disruption of anterior cruciate ligament of unspecified knee

M23.621 Other spontaneous disruption of posterior cruciate ligament of right knee

M23.622 Other spontaneous disruption of posterior cruciate ligament of left knee

M23.629 Other spontaneous disruption of posterior cruciate ligament of unspecified knee

M23.631 Other spontaneous disruption of medial collateral ligament of right knee

M23.632 Other spontaneous disruption of medial collateral ligament of left knee

M23.639 Other spontaneous disruption of medial collateral ligament of unspecified knee

M23.641 Other spontaneous disruption of lateral collateral ligament of right knee

M23.642 Other spontaneous disruption of lateral collateral ligament of left knee

M23.649 Other spontaneous disruption of lateral collateral ligament of unspecified knee

M23.671 Other spontaneous disruption of capsular ligament of right knee

M23.672 Other spontaneous disruption of capsular ligament of left knee

M23.679 Other spontaneous disruption of capsular ligament of unspecified knee

M23.8x1 Other internal derangements of right knee

M23.8x2 Other internal derangements of left knee

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

M23.8x9 Other internal derangements of unspecified knee

M23.90 Unspecified internal derangement of unspecified knee

M23.91 Unspecified internal derangement of right knee

M23.92 Unspecified internal derangement of left knee

M25.261 Flail joint, right knee

M25.262 Flail joint, left knee

M25.269 Flail joint, unspecified knee

M25.361 Other instability, right knee

M25.362 Other instability, left knee

M25.369 Other instability, unspecified knee

M66.261 Spontaneous rupture of extensor tendons, right lower leg

M66.262 Spontaneous rupture of extensor tendons, left lower leg

M66.269 Spontaneous rupture of extensor tendons, unspecified lower leg

Q68.6 Discoid meniscus

S81.009a Unspecified open wound, unspecified knee, initial encounter

S82.001a Unspecified fracture of right patella, initial encounter for closed fracture

S82.001b Unspecified fracture of right patella, initial encounter for open fracture type I or II

S82.001c Unspecified fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.002a Unspecified fracture of left patella, initial encounter for closed fracture

S82.002b Unspecified fracture of left patella, initial encounter for open fracture type I or II

S82.002c Unspecified fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.009a Unspecified fracture of unspecified patella, initial encounter for closed fracture

S82.009b Unspecified fracture of unspecified patella, initial encounter for open fracture type I or II

S82.009c Unspecified fracture of unspecified patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.011a Displaced osteochondral fracture of right patella, initial encounter for closed fracture

S82.011b Displaced osteochondral fracture of right patella, initial encounter for open fracture type I or II

S82.011c Displaced osteochondral fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.012a Displaced osteochondral fracture of left patella, initial encounter for closed fracture

S82.012b Displaced osteochondral fracture of left patella, initial encounter for open fracture type I or II

S82.012c Displaced osteochondral fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.013a Displaced osteochondral fracture of unspecified patella, initial encounter for closed fracture

S82.013b Displaced osteochondral fracture of unspecified patella, initial encounter for open fracture type I or II

S82.013c Displaced osteochondral fracture of unspecified patella, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S82.014a Nondisplaced osteochondral fracture of right patella, initial encounter for closed fracture

S82.014b Nondisplaced osteochondral fracture of right patella, initial encounter for open fracture type I or II

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

S82.014c Nondisplaced osteochondral fracture of right patella, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S82.015a Nondisplaced osteochondral fracture of left patella, initial encounter for closed fracture

S82.015b Nondisplaced osteochondral fracture of left patella, initial encounter for open fracture type I or II

S82.015c Nondisplaced osteochondral fracture of left patella, initial encounter for open fracture type IIIA, IIIB,

or IIIC

S82.016a Nondisplaced osteochondral fracture of unspecified patella, initial encounter for closed fracture

S82.016b Nondisplaced osteochondral fracture of unspecified patella, initial encounter for open fracture type I

or II

S82.016c Nondisplaced osteochondral fracture of unspecified patella, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S82.021a Displaced longitudinal fracture of right patella, initial encounter for closed fracture

S82.021b Displaced longitudinal fracture of right patella, initial encounter for open fracture type I or II

S82.021c Displaced longitudinal fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.022a Displaced longitudinal fracture of left patella, initial encounter for closed fracture

S82.022b Displaced longitudinal fracture of left patella, initial encounter for open fracture type I or II

S82.022c Displaced longitudinal fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.023a Displaced longitudinal fracture of unspecified patella, initial encounter for closed fracture

S82.023b Displaced longitudinal fracture of unspecified patella, initial encounter for open fracture type I or II

S82.023c Displaced longitudinal fracture of unspecified patella, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S82.024a Nondisplaced longitudinal fracture of right patella, initial encounter for closed fracture

S82.024b Nondisplaced longitudinal fracture of right patella, initial encounter for open fracture type I or II

S82.024c Nondisplaced longitudinal fracture of right patella, initial encounter for open fracture type IIIA, IIIB,

or IIIC

S82.025a Nondisplaced longitudinal fracture of left patella, initial encounter for closed fracture

S82.025b Nondisplaced longitudinal fracture of left patella, initial encounter for open fracture type I or II

S82.025c Nondisplaced longitudinal fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.026a Nondisplaced longitudinal fracture of unspecified patella, initial encounter for closed fracture

S82.026b Nondisplaced longitudinal fracture of unspecified patella, initial encounter for open fracture type I or

II

S82.026c Nondisplaced longitudinal fracture of unspecified patella, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S82.031a Displaced transverse fracture of right patella, initial encounter for closed fracture

S82.031b Displaced transverse fracture of right patella, initial encounter for open fracture type I or II

S82.031c Displaced transverse fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.032a Displaced transverse fracture of left patella, initial encounter for closed fracture

S82.032b Displaced transverse fracture of left patella, initial encounter for open fracture type I or II

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

S82.032c Displaced transverse fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.033a Displaced transverse fracture of unspecified patella, initial encounter for closed fracture

S82.033b Displaced transverse fracture of unspecified patella, initial encounter for open fracture type I or II

S82.033c Displaced transverse fracture of unspecified patella, initial encounter for open fracture type IIIA, IIIB,

or IIIC

S82.034a Nondisplaced transverse fracture of right patella, initial encounter for closed fracture

S82.034b Nondisplaced transverse fracture of right patella, initial encounter for open fracture type I or II

S82.034c Nondisplaced transverse fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.035a Nondisplaced transverse fracture of left patella, initial encounter for closed fracture

S82.035b Nondisplaced transverse fracture of left patella, initial encounter for open fracture type I or II

S82.035c Nondisplaced transverse fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.036a Nondisplaced transverse fracture of unspecified patella, initial encounter for closed fracture

S82.036b Nondisplaced transverse fracture of unspecified patella, initial encounter for open fracture type I or II

S82.036c Nondisplaced transverse fracture of unspecified patella, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S82.041a Displaced comminuted fracture of right patella, initial encounter for closed fracture

S82.041b Displaced comminuted fracture of right patella, initial encounter for open fracture type I or II

S82.041c Displaced comminuted fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.042a Displaced comminuted fracture of left patella, initial encounter for closed fracture

S82.042b Displaced comminuted fracture of left patella, initial encounter for open fracture type I or II

S82.042c Displaced comminuted fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S82.043a Displaced comminuted fracture of unspecified patella, initial encounter for closed fracture

S82.043b Displaced comminuted fracture of unspecified patella, initial encounter for open fracture type I or II

S82.043c Displaced comminuted fracture of unspecified patella, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S82.044a Nondisplaced comminuted fracture of right patella, initial encounter for closed fracture

S82.044b Nondisplaced comminuted fracture of right patella, initial encounter for open fracture type I or II

S82.044c Nondisplaced comminuted fracture of right patella, initial encounter for open fracture type IIIA, IIIB,

or IIIC

S82.045a Nondisplaced comminuted fracture of left patella, initial encounter for closed fracture

S82.045b Nondisplaced comminuted fracture of left patella, initial encounter for open fracture type I or II

S82.045c Nondisplaced comminuted fracture of left patella, initial encounter for open fracture type IIIA, IIIB,

or IIIC

S82.046a Nondisplaced comminuted fracture of unspecified patella, initial encounter for closed fracture

S82.046b Nondisplaced comminuted fracture of unspecified patella, initial encounter for open fracture type I or

II

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

S82.046c Nondisplaced comminuted fracture of unspecified patella, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S82.091a Other fracture of right patella, initial encounter for closed fracture

S82.091b Other fracture of right patella, initial encounter for open fracture type I or II

S82.091c Other fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.092a Other fracture of left patella, initial encounter for closed fracture

S82.092b Other fracture of left patella, initial encounter for open fracture type I or II

S82.092c Other fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.099a Other fracture of unspecified patella, initial encounter for closed fracture

S82.099b Other fracture of unspecified patella, initial encounter for open fracture type I or II

S82.099c Other fracture of unspecified patella, initial encounter for open fracture type IIIA, IIIB, or IIIC

S83.001a Unspecified subluxation of right patella, initial encounter

S83.002a Unspecified subluxation of left patella, initial encounter

S83.003a Unspecified subluxation of unspecified patella, initial encounter

S83.004a Unspecified dislocation of right patella, initial encounter

S83.005a Unspecified dislocation of left patella, initial encounter

S83.006a Unspecified dislocation of unspecified patella, initial encounter

S83.011a Lateral subluxation of right patella, initial encounter

S83.012a Lateral subluxation of left patella, initial encounter

S83.013a Lateral subluxation of unspecified patella, initial encounter

S83.014a Lateral dislocation of right patella, initial encounter

S83.015a Lateral dislocation of left patella, initial encounter

S83.016a Lateral dislocation of unspecified patella, initial encounter

S83.091a Other subluxation of right patella, initial encounter

S83.092a Other subluxation of left patella, initial encounter

S83.093a Other subluxation of unspecified patella, initial encounter

S83.094a Other dislocation of right patella, initial encounter

S83.095a Other dislocation of left patella, initial encounter

S83.096a Other dislocation of unspecified patella, initial encounter

S83.101a Unspecified subluxation of right knee, initial encounter

S83.102a Unspecified subluxation of left knee, initial encounter

S83.103a Unspecified subluxation of unspecified knee, initial encounter

S83.104a Unspecified dislocation of right knee, initial encounter

S83.105a Unspecified dislocation of left knee, initial encounter

S83.106a Unspecified dislocation of unspecified knee, initial encounter

S83.111a Anterior subluxation of proximal end of tibia, right knee, initial encounter

S83.112a Anterior subluxation of proximal end of tibia, left knee, initial encounter

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

S83.113a Anterior subluxation of proximal end of tibia, unspecified knee, initial encounter

S83.114a Anterior dislocation of proximal end of tibia, right knee, initial encounter

S83.115a Anterior dislocation of proximal end of tibia, left knee, initial encounter

S83.116a Anterior dislocation of proximal end of tibia, unspecified knee, initial encounter

S83.121a Posterior subluxation of proximal end of tibia, right knee, initial encounter

S83.122a Posterior subluxation of proximal end of tibia, left knee, initial encounter

S83.123a Posterior subluxation of proximal end of tibia, unspecified knee, initial encounter

S83.124a Posterior dislocation of proximal end of tibia, right knee, initial encounter

S83.125a Posterior dislocation of proximal end of tibia, left knee, initial encounter

S83.126a Posterior dislocation of proximal end of tibia, unspecified knee, initial encounter

S83.131a Medial subluxation of proximal end of tibia, right knee, initial encounter

S83.132a Medial subluxation of proximal end of tibia, left knee, initial encounter

S83.133a Medial subluxation of proximal end of tibia, unspecified knee, initial encounter

S83.134a Medial dislocation of proximal end of tibia, right knee, initial encounter

S83.135a Medial dislocation of proximal end of tibia, left knee, initial encounter

S83.136a Medial dislocation of proximal end of tibia, unspecified knee, initial encounter

S83.146a Lateral dislocation of proximal end of tibia, unspecified knee, initial encounter

S83.191a Other subluxation of right knee, initial encounter

S83.192a Other subluxation of left knee, initial encounter

S83.193a Other subluxation of unspecified knee, initial encounter

S83.194a Other dislocation of right knee, initial encounter

S83.195a Other dislocation of left knee, initial encounter

S83.196a Other dislocation of unspecified knee, initial encounter

S83.200a Bucket-handle tear of unspecified meniscus, current injury, right knee, initial encounter

S83.201a Bucket-handle tear of unspecified meniscus, current injury, left knee, initial encounter

S83.202a Bucket-handle tear of unspecified meniscus, current injury, unspecified knee, initial encounter

S83.203a Other tear of unspecified meniscus, current injury, right knee, initial encounter

S83.204a Other tear of unspecified meniscus, current injury, left knee, initial encounter

S83.205a Other tear of unspecified meniscus, current injury, unspecified knee, initial encounter

S83.206a Unspecified tear of unspecified meniscus, current injury, right knee, initial encounter

S83.207a Unspecified tear of unspecified meniscus, current injury, left knee, initial encounter

S83.209a Unspecified tear of unspecified meniscus, current injury, unspecified knee, initial encounter

S83.211a Bucket-handle tear of medial meniscus, current injury, right knee, initial encounter

S83.212a Bucket-handle tear of medial meniscus, current injury, left knee, initial encounter

S83.219a Bucket-handle tear of medial meniscus, current injury, unspecified knee, initial encounter

S83.221a Peripheral tear of medial meniscus, current injury, right knee, initial encounter

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

S83.222a Peripheral tear of medial meniscus, current injury, left knee, initial encounter

S83.229a Peripheral tear of medial meniscus, current injury, unspecified knee, initial encounter

S83.231a Complex tear of medial meniscus, current injury, right knee, initial encounter

S83.232a Complex tear of medial meniscus, current injury, left knee, initial encounter

S83.239a Complex tear of medial meniscus, current injury, unspecified knee, initial encounter

S83.241a Other tear of medial meniscus, current injury, right knee, initial encounter

S83.242a Other tear of medial meniscus, current injury, left knee, initial encounter

S83.249a Other tear of medial meniscus, current injury, unspecified knee, initial encounter

S83.251a Bucket-handle tear of lateral meniscus, current injury, right knee, initial encounter

S83.252a Bucket-handle tear of lateral meniscus, current injury, left knee, initial encounter

S83.259a Bucket-handle tear of lateral meniscus, current injury, unspecified knee, initial encounter

S83.261a Peripheral tear of lateral meniscus, current injury, right knee, initial encounter

S83.262a Peripheral tear of lateral meniscus, current injury, left knee, initial encounter

S83.269a Peripheral tear of lateral meniscus, current injury, unspecified knee, initial encounter

S83.271a Complex tear of lateral meniscus, current injury, right knee, initial encounter

S83.272a Complex tear of lateral meniscus, current injury, left knee, initial encounter

S83.279a Complex tear of lateral meniscus, current injury, unspecified knee, initial encounter

S83.281a Other tear of lateral meniscus, current injury, right knee, initial encounter

S83.282a Other tear of lateral meniscus, current injury, left knee, initial encounter

S83.289a Other tear of lateral meniscus, current injury, unspecified knee, initial encounter

S83.30xa Tear of articular cartilage of unspecified knee, current, initial encounter

S83.31xa Tear of articular cartilage of right knee, current, initial encounter

S83.32xa Tear of articular cartilage of left knee, current, initial encounter

S83.401a Sprain of unspecified collateral ligament of right knee, initial encounter

S83.402a Sprain of unspecified collateral ligament of left knee, initial encounter

S83.409a Sprain of unspecified collateral ligament of unspecified knee, initial encounter

S83.411a Sprain of medial collateral ligament of right knee, initial encounter

S83.412a Sprain of medial collateral ligament of left knee, initial encounter

S83.419a Sprain of medial collateral ligament of unspecified knee, initial encounter

S83.421a Sprain of lateral collateral ligament of right knee, initial encounter

S83.422a Sprain of lateral collateral ligament of left knee, initial encounter

S83.429a Sprain of lateral collateral ligament of unspecified knee, initial encounter

S83.501a Sprain of unspecified cruciate ligament of right knee, initial encounter

S83.502a Sprain of unspecified cruciate ligament of left knee, initial encounter

S83.509a Sprain of unspecified cruciate ligament of unspecified knee, initial encounter

S83.511a Sprain of anterior cruciate ligament of right knee, initial encounter

MEDICAL POLICY




ICD-10-CM

Diagnosis

Code*

Description

S83.512a Sprain of anterior cruciate ligament of left knee, initial encounter

S83.519a Sprain of anterior cruciate ligament of unspecified knee, initial encounter

S83.521a Sprain of posterior cruciate ligament of right knee, initial encounter

S83.522a Sprain of posterior cruciate ligament of left knee, initial encounter

S83.529a Sprain of posterior cruciate ligament of unspecified knee, initial encounter

S83.60xa Sprain of the superior tibiofibular joint and ligament, unspecified knee, initial encounter

S83.61xa Sprain of the superior tibiofibular joint and ligament, right knee, initial encounter

S83.62xa Sprain of the superior tibiofibular joint and ligament, left knee, initial encounter

S83.8x1a Sprain of other specified parts of right knee, initial encounter

S83.8x2a Sprain of other specified parts of knee, initial encounter

S83.8x9a Sprain of other specified parts of knee, initial encounter

S83.90xa Sprain of unspecified site of unspecified knee, initial encounter

S86.911a Strain of unspecified muscle(s) and tendon(s) at lower leg level, right leg, initial encounter

S86.912a Strain of unspecified muscle(s) and tendon(s) at lower leg level, left leg, initial encounter

S86.919a Strain of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter

S83.91xa Sprain of unspecified site of right knee, initial encounter

S83.92xa Sprain of unspecified site of left knee, initial encounter

S86.111a Strain of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, initial

encounter

S86.112a Strain of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, left leg, initial

encounter

S86.119a Strain of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg,

initial encounter

S86.211a Strain of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, initial

encounter

S86.212a Strain of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg, initial encounter

S86.219a Strain of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, initial

encounter

S86.311a Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, initial

encounter

S86.312a Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, initial

encounter

S86.319a Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, unspecified leg, initial

encounter

S86.811a Strain of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter

S86.812a Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter

S86.819a Strain of other muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter

*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.

MEDICAL POLICY




X. POLICY HISTORY

MP-6.012 CAC 2/25/03

CAC 9/28/04

CAC 9/27/05

CAC 11/28/06

CAC 2/27/07

CAC 1/29/08 Consensus

CAC 7/29/08

CAC 7/28/09

CAC 7/27/10 Consensus review.

CAC 10/25/11 Adopt BCBSA. Information related to individual consideration for

custom-made functional knee braces was retained in the policy.

CAC 10/30/12 consensus. No change to policy statements. References updated.

Codes reviewed 10/23/12 klr

CAC 11/26/13 Consensus review. No change to policy statements. References

updated. Rationale added.

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®,

Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association.

Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

Documents

KNEE BRACES 6 - AAPC