LCD for Orthopedic Footwear (L11467)

 

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Contractor Information

Contractor Name 

NHIC 

Contractor Number 

16003 

Contractor Type 

DME MAC 

 

LCD Information

LCD ID Number 

L11467 

 

LCD Title 

Orthopedic Footwear 

 

Contractor's Determination Number 

ORFW20080701 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.10 

 

Primary Geographic Jurisdiction 

Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode Island
Vermont
 

 

Oversight Region 

Region III
 

 

 

DME Region LCD Covers 

Jurisdiction A 

 

Original Determination Effective Date 

For services performed on or after 01/01/1995  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 01/01/2008  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

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 an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

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

 

Coverage Topic 

Braces (arm, leg, back, and neck)
Therapeutic Shoes
 

 

Coding Information

 

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
KX - Specific required documentation on file
LT - Left side
RT - Right side

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

 

 

Diagnoses that Support Medical Necessity 

For the specific HCPCS code indicated above, refer to the previous section.

For all other HCPCS codes, diagnoses are not specified. 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

For the specific HCPCS code indicated above, all ICD-9 codes that are not specified in the previous section.

For all other HCPCS codes, ICD-9 codes are not specified.

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

For the specific HCPCS code indicated above, all diagnoses that are not specified in the previous section.

For all other HCPCS codes, diagnoses are not specified. 

 

General Information

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

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.

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 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.

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

 

Appendices 

 

 

Utilization Guidelines 

Refer to Indications and Limitations of Coverage and/or Medical Necessity. 

 

Sources of Information and Basis for Decision 

Reserved for future use. 

 

Advisory Committee Meeting Notes 

 

 

Start Date of Comment Period 

 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

01/01/1995 

 

Revision History Number 

ORFW006 

 

Revision History Explanation 

3/1/2008- In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC NHIC (16003) LCD L11467 from DME PSC TriCenturion (77011) LCD L11467.

Revision Effective Date: 01/01/2008
HCPCS CODES:
Added: A9283

Revision Effective Date: 07/01/2007
INDICATONS AND LIMITATIONS:
Removed: DMERC references
DOCUMENTATION REQUIREMENTS:
Removed: DMERC references

 

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).

Revision Effective Date: 01/01/2006
HCPCS CODES AND MODIFIERS:
Added: L3031
Revised: L3170, L3215, L3216, L3217, L3219, L3221, L3222, L3230

Revision effective date: 10/01/2005
LMRP converted to LCD and Policy Article
DOCUMENTATION REQUIREMENTS:
Eliminated the requirement for an ICD-9 code on the order for L3250.
Deleted reference to filing hard copy claims.

 

09/04/2004 - This policy was updated by the ICD-9 Code Annual Update for 2004-2005.

Revision effective date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: EY
Discontinued: L3218, L3223
Revised: L3260
INDICATIONS AND LIMITATIONS OF COVERAGE:
Adds standard language concerning coverage of items without an order.
DOCUMENTATION REQUIREMENTS:
Adds standard language concerning use of EY modifier for items without an order.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

07/01/2002 - Replaced the ZX modifier with KX. Updated the
codes for therapeutic shoes for diabetics.

07/01/2000 – Added reasonable and necessary language to Coverage and Payment Rules section.




 

 

Last Reviewed On Date 

 

 

Related Documents 

Article(s)
A35348 - Orthopedic Footwear - Policy Article - Effective January 2008

 

LCD Attachments 

There are no attachments for this LCD

 

Article for Orthopedic Footwear - Policy Article - Effective January 2008 (A35348)

 

Top of Form

 

 

Contractor Information

Contractor Name 

NHIC 

Contractor Number 

16003 

Contractor Type 

DME MAC 

 

Article Information

Article ID Number 

A35348 

Article Type 

Article

Key Article 

Yes

Article Title 

Orthopedic Footwear - Policy Article - Effective January 2008 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

Primary Geographic Jurisdiction 

Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode Island
Vermont
 

DME Region Article Covers 

Jurisdiction A 

Original Article Effective Date 

10/01/2005

Article Revision Effective Date 

01/01/2008

Article Text 

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

Shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected patients with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes (A5500-A5511) are used for footwear provided under this benefit. See the medical policy on Therapeutic Shoes for Diabetics for details.

Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980-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-L3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-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-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-L3649 will be denied as noncovered.


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-L3253, or L3649 without a KX modifier.

Depth-inlay or custom molded shoes for diabetics (A5500-A5501) and related inserts and modifications (A5503-A5511) are billed using these A codes whether or not the shoe is an integral part of a brace. (See policy on Therapeutic Shoes for Diabetics for coverage, documentation, and additional coding guidelines.)

Code A9283 (foot pressure off-loading/ supportive device) is used for a item that is designed primarily to reduce pressure on the sole or heel of the foot but that does not meet the definition of:
a) A therapeutic shoe for diabetics or related insert or modification; or
b) An orthopedic shoe or modification; or
c) 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 patient 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-L5600) that are attached to the residual limb by other mechanisms.

The right (RT) and left (LT) modifiers must be used with footwear codes. When bilateral items are provided on the same date of service, bill both on the same claim line using the LTRT modifier and 2 units of service.

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

Coverage Topic 

Braces (arm, leg, back, and neck)
Therapeutic Shoes
 

 

Coding Information

No Coding Information has been entered in this section of the article.

 

Other Information

Revision History Explanation 

3/1/2008- In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC NHIC (16003) Article A35348 from DME PSC TriCenturion (77011) Article A35348.

Revision Effective Date: 01/01/2008
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Noncoverage of A9283
CODING GUIDELINES:
Added: Definition of A9283