Ask the AOPA Expert

Common Questions on Billing Shoes
By Joe McTernan

Q: Will Medicare cover a diabetic shoe worn over a prosthetic foot?
A: Medicare allows for coverage of one pair of shoes per calendar year, provided that the patient has diabetes mellitus and a secondary condition, such as previous amputation of the other foot, or part of either foot. This implies that, when a diabetic shoe is being used to treat the sound foot, a basic shoe will also be covered for the prosthetic foot on the other side. There is no medical need, however, for a custom shoe or any inserts for the shoe that is placed over the prosthesis.

Q: Can a patient receive a pair of therapeutic shoes in November and again the following January?
A: Yes. The Medicare benefit for therapeutic shoes is based on a calendar year. However, while the benefit is available, the medical need for the new shoes must be established before Medicare will pay for them. With such a short time span between delivery dates, you should expect a request for additional documentation to support the medical necessity of the new pair.

Q: How do I code for a pair of shoes when a diabetic patient also uses a brace attached to a shoe on one of their legs?
A: In this scenario, you may code the shoe attached to the brace as either a therapeutic shoe (A5500/A5501) or a shoe attached to a brace (L3224/L3225).

Q: Do I have to accept assignment on Medicare claims for therapeutic shoes?
A: If you have agreed to be a participating provider, you are required to accept assignment for all Medicare claims. If you elect not to be a participating provider in the Medicare program, you may choose to accept assignment or not accept assignment on an individual claim basis.

Q: Are therapeutic shoes listed on the Medicare fee schedule?
A: Yes. Therapeutic shoes were traditionally paid on a reasonable charge basis, with a congressionally-mandated ceiling amount. In 2005, as a result of the Medicare Modernization Act, reimbursement for therapeutic shoes was converted to a fee schedule basis. Medicare will now pay the lesser of your submitted charge or the published fee schedule amount.

Q: Should I have all Medicare patients sign an Advanced Beneficiary Notice (ABN) when providing them with therapeutic shoes?
A: No. Medicare policy only allows you to ask the patient to sign an ABN if you have a specific reason to believe that Medicare will deem the service not medically necessary. The use of blanket ABNs for any service is not allowed by Medicare.

Q: If a patient requests a specific cosmetic feature for a therapeutic shoe (e.g., wingtip stitching), will Medicare cover the shoe?
A: Medicare will cover the shoe itself, but will not cover the patient-requested upgrade. Anything that is cosmetic in nature should be billed using A5508. This code applies to deluxe features of a single off-the-shelf depth inlay shoe or custom-molded shoe for diabetics. Claims for A5508 should include a GY modifier to indicate that the upgrade is a non-covered service. The Medicare patient may be billed directly for the cost of the upgrade.

Q: Will Medicare cover repairs to therapeutic shoes?
A: Yes. Medicare policy states that repairs to therapeutic shoes are covered and should be billed using A5507 (not otherwise specified modification, including fitting, of a single off-the-shelf depth-inlay shoe or custom molded shoe, for diabetes only).

Q: How many modifications to a therapeutic shoe will Medicare cover?
A: For each modification you provide, the number of inserts covered by Medicare will be reduced by one. For custom therapeutic shoes, Medicare will cover two additional inserts (since one insert is included with the shoe itself) or two modifications. For an off-the-shelf therapeutic shoe, Medicare will cover three inserts or three modifications.

Q: How do I bill for a custom orthopedic shoe attached to a brace?
A: Medicare policy states that if a custom shoe is necessary for the brace to function properly, it must be coded as L3649 (orthopedic shoe, modification, addition or transfer, not otherwise specified).

Q: Can a podiatrist sign a certifying statement for therapeutic shoes?
A: No. The physician who signs the certifying statement must be the M.D. or D.O. responsible for managing the patient’s diabetes. While podiatrists may write the prescription for the shoes, they may not sign the certifying statement, since diabetes management is outside of their scope of practice.

Joe McTernan is assistant director of reimbursement services at AOPA. Call him with your coding and billing questions at (571) 431-0811, or e-mail jmcternan@AOPAnet.org.

Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession.