Local Coverage Article

Orthopedic Footwear - Policy Article

A52481

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A52481
Original ICD-9 Article ID
A35426
A35359
A47239
A35348
Article Title
Orthopedic Footwear - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2020 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. "reasonable and necessary").

Orthopedic footwear is covered under the leg, arm, back, and neck braces, and artificial legs, arms and eyes benefit (Social Security Act §1861(s)(9)). In order for a beneficiary's DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes are used for footwear provided under this benefit. See the medical policy on Therapeutic Shoes for Persons with Diabetes for details.

Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, L3225) are covered in these situations. Other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600, L3610, L3620, L3630 and L3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded.

According to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements, are covered only when the shoe is an integral part of a brace. A matching shoe which is not attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as noncovered because coverage is statutorily excluded.

Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace. Shoes which are billed separately (i.e., not as part of a brace) will be denied as noncovered. A KX modifier must not be used in this situation.

Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595 and L5600) which is attached to the residual limb by other mechanisms because there is no Medicare benefit for these items.

A foot pressure off-loading/ supportive device (A9283) is denied as noncovered because there is no Medicare benefit category for these items.

With the exception of the situations described above, orthopedic footwear billed using codes L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610 ,L3620, L3630, L3640, and L3649 will be denied as noncovered.


REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The link will be located here once it is available.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.


POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

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


MODIFERS

KX and GY MODIFIERS:

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

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.

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

When billing for prosthetic shoes (L3250) and related items, 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.

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


CODING GUIDELINES

Oxford shoes that are an integral part of a brace are billed using codes L3224 or L3225 with a KX modifier. For these codes, one unit of service is each shoe. Oxford shoes that are not part of a leg brace must be billed with codes L3215 or L3219 without a KX modifier.

Other shoes (e.g., high top, depth inlay or custom shoes for non-diabetics, etc.) that are an integral part of a brace are billed using code L3649 with a KX modifier. Other shoes that are not an integral part of a brace must be billed using codes L3216, L3217, L3221, L3222, L3230, L3251, L3252, L3253, or L3649 without a KX modifier.

Depth-inlay or custom molded shoes for diabetics and related inserts and modifications are billed using A codes whether or not the shoe is an integral part of a brace. See the medical policy on Therapeutic Shoes for Persons with Diabetes for coverage, documentation, and additional coding guidelines.

Code A9283 (foot pressure off-loading/ supportive device) is used for an item that is designed primarily to reduce pressure on the sole or heel of the foot but that does not meet the definition of:

  1. A therapeutic shoe for diabetics or related insert or modification; or
  2. An orthopedic shoe or modification; or
  3. A walking boot

It may be a shoe-like item, an item that is used inside a shoe and may or may not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated.

Code L3250 may be used only for a shoe that is custom fabricated from a model of a beneficiary and has a removable custom fabricated insert designed for toe or distal partial foot amputation. The shoe serves to hold the insert on the leg. Code L3250 must not be used for a shoe that is put on other types of leg prostheses (L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595 and L5600) that are attached to the residual limb by other mechanisms.

The right (RT) and/or left (LT) modifiers must be used with all footwear HCPCS codes in this policy. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on “Coverage Indications, Limitations, and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS code L3250:

Group 1 Codes
CodeDescription
Q72.00 Congenital complete absence of unspecified lower limb
Q72.01 Congenital complete absence of right lower limb
Q72.02 Congenital complete absence of left lower limb
Q72.03 Congenital complete absence of lower limb, bilateral
Q72.30 Congenital absence of unspecified foot and toe(s)
Q72.31 Congenital absence of right foot and toe(s)
Q72.32 Congenital absence of left foot and toe(s)
Q72.33 Congenital absence of foot and toe(s), bilateral
Q72.70 Split foot, unspecified lower limb
Q72.71 Split foot, right lower limb
Q72.72 Split foot, left lower limb
Q72.73 Split foot, bilateral
S98.011A Complete traumatic amputation of right foot at ankle level, initial encounter
S98.011D Complete traumatic amputation of right foot at ankle level, subsequent encounter
S98.012A Complete traumatic amputation of left foot at ankle level, initial encounter
S98.012D Complete traumatic amputation of left foot at ankle level, subsequent encounter
S98.019A Complete traumatic amputation of unspecified foot at ankle level, initial encounter
S98.019D Complete traumatic amputation of unspecified foot at ankle level, subsequent encounter
S98.021A Partial traumatic amputation of right foot at ankle level, initial encounter
S98.021D Partial traumatic amputation of right foot at ankle level, subsequent encounter
S98.022A Partial traumatic amputation of left foot at ankle level, initial encounter
S98.022D Partial traumatic amputation of left foot at ankle level, subsequent encounter
S98.029A Partial traumatic amputation of unspecified foot at ankle level, initial encounter
S98.029D Partial traumatic amputation of unspecified foot at ankle level, subsequent encounter
S98.111A Complete traumatic amputation of right great toe, initial encounter
S98.111D Complete traumatic amputation of right great toe, subsequent encounter
S98.112A Complete traumatic amputation of left great toe, initial encounter
S98.112D Complete traumatic amputation of left great toe, subsequent encounter
S98.119A Complete traumatic amputation of unspecified great toe, initial encounter
S98.119D Complete traumatic amputation of unspecified great toe, subsequent encounter
S98.121A Partial traumatic amputation of right great toe, initial encounter
S98.121D Partial traumatic amputation of right great toe, subsequent encounter
S98.122A Partial traumatic amputation of left great toe, initial encounter
S98.122D Partial traumatic amputation of left great toe, subsequent encounter
S98.129A Partial traumatic amputation of unspecified great toe, initial encounter
S98.129D Partial traumatic amputation of unspecified great toe, subsequent encounter
S98.131A Complete traumatic amputation of one right lesser toe, initial encounter
S98.131D Complete traumatic amputation of one right lesser toe, subsequent encounter
S98.132A Complete traumatic amputation of one left lesser toe, initial encounter
S98.132D Complete traumatic amputation of one left lesser toe, subsequent encounter
S98.139A Complete traumatic amputation of one unspecified lesser toe, initial encounter
S98.139D Complete traumatic amputation of one unspecified lesser toe, subsequent encounter
S98.141A Partial traumatic amputation of one right lesser toe, initial encounter
S98.141D Partial traumatic amputation of one right lesser toe, subsequent encounter
S98.142A Partial traumatic amputation of one left lesser toe, initial encounter
S98.142D Partial traumatic amputation of one left lesser toe, subsequent encounter
S98.149A Partial traumatic amputation of one unspecified lesser toe, initial encounter
S98.149D Partial traumatic amputation of one unspecified lesser toe, subsequent encounter
S98.211A Complete traumatic amputation of two or more right lesser toes, initial encounter
S98.211D Complete traumatic amputation of two or more right lesser toes, subsequent encounter
S98.212A Complete traumatic amputation of two or more left lesser toes, initial encounter
S98.212D Complete traumatic amputation of two or more left lesser toes, subsequent encounter
S98.219A Complete traumatic amputation of two or more unspecified lesser toes, initial encounter
S98.219D Complete traumatic amputation of two or more unspecified lesser toes, subsequent encounter
S98.221A Partial traumatic amputation of two or more right lesser toes, initial encounter
S98.221D Partial traumatic amputation of two or more right lesser toes, subsequent encounter
S98.222A Partial traumatic amputation of two or more left lesser toes, initial encounter
S98.222D Partial traumatic amputation of two or more left lesser toes, subsequent encounter
S98.229A Partial traumatic amputation of two or more unspecified lesser toes, initial encounter
S98.229D Partial traumatic amputation of two or more unspecified lesser toes, subsequent encounter
S98.311A Complete traumatic amputation of right midfoot, initial encounter
S98.311D Complete traumatic amputation of right midfoot, subsequent encounter
S98.312A Complete traumatic amputation of left midfoot, initial encounter
S98.312D Complete traumatic amputation of left midfoot, subsequent encounter
S98.319A Complete traumatic amputation of unspecified midfoot, initial encounter
S98.319D Complete traumatic amputation of unspecified midfoot, subsequent encounter
S98.321A Partial traumatic amputation of right midfoot, initial encounter
S98.321D Partial traumatic amputation of right midfoot, subsequent encounter
S98.322A Partial traumatic amputation of left midfoot, initial encounter
S98.322D Partial traumatic amputation of left midfoot, subsequent encounter
S98.329A Partial traumatic amputation of unspecified midfoot, initial encounter
S98.329D Partial traumatic amputation of unspecified midfoot, subsequent encounter
S98.911A Complete traumatic amputation of right foot, level unspecified, initial encounter
S98.911D Complete traumatic amputation of right foot, level unspecified, subsequent encounter
S98.912A Complete traumatic amputation of left foot, level unspecified, initial encounter
S98.912D Complete traumatic amputation of left foot, level unspecified, subsequent encounter
S98.919A Complete traumatic amputation of unspecified foot, level unspecified, initial encounter
S98.919D Complete traumatic amputation of unspecified foot, level unspecified, subsequent encounter
S98.921A Partial traumatic amputation of right foot, level unspecified, initial encounter
S98.921D Partial traumatic amputation of right foot, level unspecified, subsequent encounter
S98.922A Partial traumatic amputation of left foot, level unspecified, initial encounter
S98.922D Partial traumatic amputation of left foot, level unspecified, subsequent encounter
S98.929A Partial traumatic amputation of unspecified foot, level unspecified, initial encounter
S98.929D Partial traumatic amputation of unspecified foot, level unspecified, subsequent encounter

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

For the specific HCPCS code indicated above, all ICD-10 codes that are not specified in the previous section.

For all other HCPCS codes, ICD-10 codes are not specified.

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

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

N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2020 R5

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: HCPCS code L3000 to noncovered statement, previously omitted in error

03/11/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R4

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
Removed: Therapeutic Shoes for Persons with Diabetes codes, leaving reference to the policy
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
CODING GUIDELINES:
Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
Removed: Therapeutic Shoes for Persons with Diabetes codes, leaving reference to the policy
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

 

02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2019 R3

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Revised: RT and/or LT modifier instructions
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding all unlisted diagnosis codes from coverage

02/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R2 Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Replacement order for heel or sole information and Modifiers requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016 R1 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Associated Documents

Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
03/04/2021 01/01/2020 - N/A Currently in Effect You are here
02/14/2020 01/01/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A