Reimbursement Page

Code Correctly and Get Paid:
Orthopedic and Diabetic Shoes
By Virginia Torsch

AOPA helps you sort through confusing CMS medical policies so you can get paid for the devices you provide. This article highlights the differences in coverage for orthopedic shoes versus therapeutic shoes provided to diabetics.

There are basic differences between Medicare’s coverage of orthopedic shoes and its coverage of therapeutic shoes provided to diabetics. While Medicare will usually cover a pair of therapeutic shoes provided the diabetic patient meets certain conditions, it will only cover an orthopedic shoe if it is an integral part of a brace.

Shoe coding basics
Orthopedic and therapeutic shoes differ in how they are coded. Therapeutic shoes for diabetic patients are coded with A codes, and L codes describe orthopedic shoes.

Furthermore, you cannot mix the A codes you use for therapeutic shoes with the L codes you use for orthopedic footwear. For example, you cannot use A5512 or A5513 to code inserts for orthopedic shoes. These inserts have their own L codes.

Orthopedic shoes
If you provide shoes to a patient who is not diabetic, Medicare will only cover the shoe that is an integral part of a brace. The brace must be one described by the following L codes: L1900, L1920, L1980-2030, L2050, L2060, L2080 or L2090.

Coding orthopedic shoes
For an Oxford shoe attached to a brace, use either L3224 (for women) or L3225 (for men) as appropriate. (This code is for each Oxford shoe, not the pair.) You must also use the KX modifier, which indicates to Medicare that you have the appropriate documentation required by medical policy in your patient’s file.

Get the Whole Picture This is the third in a series of four articles telling you how to code correctly in order to be reimbursed. The first article in the March 2006 O&P Almanac examined the medical policy for AFOs and KAFOs. The second article in the series covered the medical policy for lower-limb prostheses and appeared in the June 2006 O&P Almanac. Article four, in the December issue, will focus on the correct coding for spinal orthoses. These and other O&P Almanac articles can be viewed at www.AOPAnet.org/op_almanac.

So if you submit a claim for a pair of Oxford shoes, and only one shoe is attached to a brace, code the shoe attached to the brace with either L3224 or L3225 with the KX modifier and code the other shoe as L3215 or L3219 with the GY modifier for non-covered service.  Use the LT or RT modifier with the appropriate code.

If the patient has braces on both legs, both shoes will be covered. Bill the shoes as L3224 or L3225 for both shoes with the KX modifier for both. Use LTRT if both shoes are covered.

Other orthopedic shoes
If you provide a high-top shoe, a depth inlay or a custom shoe attached to a brace, use L3649 to describe these shoes.

If you use L3649 with the KX modifier, you must include a short narrative on your claim that describes why the shoe is medically necessary for the brace to function.

Describe the shoe not attached to the brace by codes L3216, L3217, L3221, L3222, L3230, L3251-L3253 or L3549 as appropriate. Do not use the KX modifier for this shoe.

Prosthetic shoes
Medicare will also cover a prosthetic shoe (L3250) if it is part of a prosthesis for a patient with a partial foot amputation (designated by an ICD diagnosis code of 755.31, 755.38, 755.39, or 895-896.3). The shoe must be custom-fabricated from a model of the patient and have a removable, custom-fabricated insert designed for a toe or partial foot amputation. You cannot use L3250 for a shoe put on over leg prostheses (described by codes L5010-L5600) that are attached to the residual limb by other mechanisms.

Know the Medical Policy You must read both the local coverage determination (LCD) and the accompanying policy article to get a complete picture of Medicare coverage of certain items. The LCD discusses coverage in terms of medical necessity—is an item reasonable and medically necessary? The policy article identifies situations where an item is not covered by a Medicare benefit category—when an item is "non-covered" rather than "not medically necessary." It also identifies situations when an item may be denied as "not separately payable." Listed below are the Web sites for LCDs and policy articles for each DMAC jurisdiction (formerly DMERC regions): Jurisdictions A and B: www.tricenturion.com/content/lmrp_current_dyn.cfm Jurisdiction C: www.palmettogba.com/palmetto/lcds.nsf/main/dmerc Jurisdiction D: www.edssafeguardservices.eds-gov.com/providers/dme/lcdcurrent.asp

 

Inserts and modifications
Inserts and other shoe modifications described by L3000-L3170, L3300-L3450, L3465-L3520, and L3550-L3595 are only covered for the shoe attached to the brace. Heel replacements (L3455, L3460), sole replacements (L3530, L3540) and shoe transfers (L3600-3640) are also covered, but only for the shoe attached to the brace.  Again, use the KX modifier with all of these codes.

Therapeutic shoes for diabetics
Medicare will usually cover a pair of shoes provided to a patient with diabetes if all three of the following criteria are met:

1. The patient has diabetes mellitus (designated by ICD-9 diagnosis codes 250 through 250.93, which must be included on the claim)

2. The patient has one or more of the following conditions:

• Previous amputation of one foot or part of foot
• History of previous foot ulceration of either foot
• History of pre-ulcerative calluses of either foot
• Peripheral neuropathy with evidence of callus formation on either foot
• Foot deformity of either foot
• Poor circulation of either foot.

3. You have a letter from the patient’s physician certifying that:

• The patient meets these criteria
• The physician is treating the patient under a comprehensive plan of care for the patient’s diabetes
• The patient needs therapeutic shoes.

CMS has developed a standard form, called a Statement of Certifying Physician for Therapeutic Shoes, that it recommends you use. Although you can complete the form for the physician, only an M.D. or D.O. can sign it; a podiatrist may not, even though a podiatrist can provide the prescription for the shoes.

Keep a copy of the statement in your file. A new certification statement is required for shoes, inserts or modifications provided more than one year from the date of the original statement.

Coding therapeutic shoes
For therapeutic shoes, Medicare will cover one of the following per calendar year:

• One pair of custom-molded shoes (A5501), including the inserts provided with the shoes, and two additional pairs of inserts (A5512 or A5513)
• One pair of off-the-shelf depth shoes (A5500) and three pairs of inserts (A5512, A5513).

Please note that, just as with the codes for orthopedic shoes, these codes describe one shoe. If you provide a pair, use the code for both shoes. You must also use the KX modifier. However, unlike the codes for orthopedic shoes, codes for diabetic shoes do not use the LTRT modifier.

Medicare will only cover a custom-molded shoe if the patient has a foot deformity that precludes the use of an off-the-shelf shoe. You must clearly document the nature and severity of the deformity. If Medicare does not find you have sufficient documentation for a custom-molded shoe, you will only be reimbursed for an off-the-shelf shoe.

CMS has developed very specific descriptions of off-the-shelf depth shoes and custom-molded shoes, and has also defined the inserts and various modifications. These descriptions can be found in the policy article “Therapeutic Shoes for Diabetics.”

Inserts and modifications
Medicare will only pay for inserts described by A5512 or A5513.

Medicare will not cover the direct-formed, compression-molded inserts described by A5510 because these inserts do not offer total contact.

In order for A5512 to be covered, the manufacturer of the insert must have had the Statistical Analysis DME Regional Carrier (SADMERC) approve its insert. When you bill for inserts coded by A5512, you must keep on file a copy of the manufacturer’s SADMERC approval letter. You can also check to see if SADMERC has added the insert to its official product classification list, which can be downloaded from the following Web site: http://snipurl.com/tffh.

As of July 1, in order to use A5513, the custom-fabricated shoe insert code, manufacturers of these inserts must have had a coding verification review performed by the Statistical Analysis DME Regional Carrier (SADMERC) that finds their product meets the Medicare requirements for this code.

Medicare defines a manufacturer as “any entity that creates inserts…then sells, ships, dispenses, or otherwise delivers the end product to someone other than the end user (patient).” However, if your facility custom-fabricates your own inserts and provides them directly to your patients, you are not considered a manufacturer and SADMERC’s approval is not necessary.

Although Medicare will cover most modifications to a therapeutic shoe—such as a roller or rigid rocker bottom (A5503), wedges (A5504) or metatarsal bars (A5505)—Medicare will not cover deluxe features (A5508). A deluxe feature is one that does not contribute to the shoe’s therapeutic function—for example, a custom style, color or custom material.

If you are replacing an insert or making a modification to the shoe within one year of the original written order, you do not need to get a new written order. However, if more than a year has elapsed, you will need a new written order from the physician or podiatrist. You also need a new order for the replacement of any shoe.

If a patient comes to you and asks for inserts because he already has therapeutic shoes, you are allowed to provide those inserts if you get written verification from the supplier of the original shoes that the inserts are appropriate for the patient’s shoes.

Pay attention, get reimbursed
However, CMS and the DMACs also occasionally publish various transmittals and bulletins that amplify the provisions in the local coverage determination (LCD) and the accompanying policy articles. You are expected to keep up with this additional guidance, so pay attention to the bulletins and transmittals issued by your DMAC.

Virginia Torsch is the assistant director of government affairs for the American Orthotic & Prosthetic Association (AOPA). AOPA is a not-for-profit trade association providing O&P-specific business services and products for professionals.

Correction: Coding for Suction Sockets and Gel Liners Medicare’s Lower Limb Prosthetic Policy states that codes L5647 and L5652, which describe suction sockets, are not to be used for gel liners (L5673, L5679, L5681, and L5683). This is often interpreted as meaning that these codes may not be billed together. While the policy indicates that the suction codes should not be used to describe the actual liners, it does not address whether they can be used together. Since L5673 is designated for use with a mechanical locking mechanism, there is no clear medical necessity for a suction socket. L5679, however, describes a liner that is not designed for use with a mechanical locking mechanism. In this instance there is no mechanical suspension present, so if a one-way valve is incorporated into the socket to achieve suction suspension of the prosthesis, both L5679 and L5647 or L5652 may be billed. L5681 and L5683 describe liners to be used with or without a mechanical locking mechanism and may be billed with L5647 or L5652 when suspension is achieved through a suction socket. This point was misstated in the June 2006 “Reimbursement Page.” If you have further questions, contact Joe McTernan at jmcternan@AOPAnet.org or (571) 431-0811.