L11445

LCD/NCD Portal

Automated World Health

L11445

ORTHOPEDIC FOOTWEAR

DME Region IV

Jurisdiction C

08/05/2011

• For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted.

o If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

• Statutory coverage criteria for orthopedic footwear are specified in the related Policy Article.

• Prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for patients with a partial foot amputation (ICD-9 diagnosis codes 755.31, 755.38, 755.39, 895.0-896.3).

o Claims for prosthetic shoes for other ICD-9 diagnosis codes will be denied as not medically necessary.

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

• The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit

KX - Requirements specified in the medical policy have been met

LT - Left side

RT - Right side

HCPCS CODES:

A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH

L3000 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, EACH

L3001 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH

L3002 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH

L3003 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACH

L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT, EACH

L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL SUPPORT, EACH

L3030 FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH

L3031 FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH

L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH

L3050 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH

L3060 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ METATARSAL, EACH

L3070 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH

L3080 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH

L3090 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATARSAL, EACH

L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT

L3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES

L3150 FOOT, ABDUCTION ROTATATION BAR, WITHOUT SHOES

L3160 FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE

L3170 FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, EACH

L3201 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT

L3202 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILD

L3203 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR

L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT

L3206 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD

L3207 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIOR

L3208 SURGICAL BOOT, EACH, INFANT

L3209 SURGICAL BOOT, EACH, CHILD

L3211 SURGICAL BOOT, EACH, JUNIOR

L3212 BENESCH BOOT, PAIR, INFANT

L3213 BENESCH BOOT, PAIR, CHILD

L3214 BENESCH BOOT, PAIR, JUNIOR

L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH

L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH

L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH

L3219 ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH

L3221 ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH

L3222 ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH

L3224 ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS)

L3225 ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS)

L3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH

L3250 ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE, EACH

L3251 FOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACH

L3252 FOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABRICATED, EACH

L3253 FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH

L3254 NON-STANDARD SIZE OR WIDTH

L3255 NON-STANDARD SIZE OR LENGTH

L3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZE

L3260 SURGICAL BOOT/SHOE, EACH

L3265 PLASTAZOTE SANDAL, EACH

L3300 LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH

L3310 LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH

L3320 LIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCH

L3330 LIFT, ELEVATION, METAL EXTENSION (SKATE)

L3332 LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH

L3334 LIFT, ELEVATION, HEEL, PER INCH

L3340 HEEL WEDGE, SACH

L3350 HEEL WEDGE

L3360 SOLE WEDGE, OUTSIDE SOLE

L3370 SOLE WEDGE, BETWEEN SOLE

L3380 CLUBFOOT WEDGE

L3390 OUTFLARE WEDGE

L3400 METATARSAL BAR WEDGE, ROCKER

L3410 METATARSAL BAR WEDGE, BETWEEN SOLE

L3420 FULL SOLE AND HEEL WEDGE, BETWEEN SOLE

L3430 HEEL, COUNTER, PLASTIC REINFORCED

L3440 HEEL, COUNTER, LEATHER REINFORCED

L3450 HEEL, SACH CUSHION TYPE

L3455 HEEL, NEW LEATHER, STANDARD

L3460 HEEL, NEW RUBBER, STANDARD

L3465 HEEL, THOMAS WITH WEDGE

L3470 HEEL, THOMAS EXTENDED TO BALL

L3480 HEEL, PAD AND DEPRESSION FOR SPUR

L3485 HEEL, PAD, REMOVABLE FOR SPUR

L3500 ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER

L3510 ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER

L3520 ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER

L3530 ORTHOPEDIC SHOE ADDITION, SOLE, HALF

L3540 ORTHOPEDIC SHOE ADDITION, SOLE, FULL

L3550 ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD

L3560 ORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOE

L3570 ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS)

L3580 ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE

L3590 ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER

L3595 ORTHOPEDIC SHOE ADDITION, MARCH BAR

L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING

L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW

L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING

L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW

L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENNIS BROWNE SPLINT (RIVETON), BOTH SHOES

L3649 ORTHOPEDIC SHOE, MODIFICATION, ADDITION OR TRANSFER, NOT OTHERWISE SPECIFIED

ICD-9 Codes that Support Medical Necessity

• The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage.

• Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS code L3250:

755.31 TRANSVERSE DEFICIENCY OF LOWER LIMB

755.38 LONGITUDINAL DEFICIENCY TARSALS OR METATARSALS COMPLETE OR PARTIAL (WITH OR WITHOUT INCOMPLETE PHALANGEAL DEFICIENCY)

755.39 LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL

895.0 - 896.3

TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL COMPLICATED

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider".

o It is expected that the patient’s medical records will reflect the need for the care provided.

o The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

• An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

o Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

• An order is not required for a heel or sole replacement or transfer of a shoe to a brace.

• KX AND GY MODIFIERS:

o When billing for a shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer, a KX modifier must be added to the code.

o If the shoe or related item is not an integral part of a leg brace, the KX modifier must not be used.

o If the shoe and related modifications, inserts, and heel/sole replacements are not an integral part of a brace, the GY modifier must be added to each code.

o If a KX or GY modifier is not included on the claim line, it will be rejected as missing information.

o When billing for prosthetic shoes (L3250) and related items, an ICD-9 diagnosis code (specific to the 5th digit), describing the condition which necessitates the prosthetic shoes, must be included on each claim for the prosthetic shoes and related items.

o When code L3649 with a KX modifier is billed, the claim must include a narrative description of the item provided as well as a brief statement of the medical necessity for the item.

o This must be entered in the narrative field of an electronic claim.

• Refer to the Supplier Manual for more information on documentation requirements.