Medicare Orthopedic Footwear Coverage
Prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for a beneficiary with a partial foot amputation (refer to the ICD-10 Codes section in the LCD-related Policy Article). Claims for prosthetic shoes for other diagnosis codes will be denied as not medically necessary.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
HCPCS CODES
Group 1 Codes
|
Code |
Description |
|
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, PREFABRICATED, OFF-THE-SHELF |
|
L3140 |
FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES |
|
L3150 |
FOOT, ABDUCTION ROTATION BAR, WITHOUT SHOES |
|
L3160 |
FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE |
|
L3170 |
FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, PREFABRICATED, OFF-THE-SHELF, 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 |
The CMS.gov website is an excellent resource for finding out about all of your options.
