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CGS Associates, LLC

June 3, 2011

Orthopedic Shoes — HCPCS Code L3000 - Billing Reminder

Recently inquires have been received regarding the proper use and billing for Healthcare Common Procedure Coding System (HCPCS) code L3000.This code describes a shoe insert billed when provided with an orthopedic shoe attached to a brace.

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

Suppliers and providers are reminded that orthopedic shoes are excluded from coverage by the Social Security Act, �1862(a)(8) except in very limited circumstances, described below. In addition, the Act specifically excludes treatment and devices for flat feet, subluxations of the foot and routine foot care (see SSA �1862(a)(13)). The only exceptions to these benefit category provisions are:

  1. Use of an orthopedic shoe(s) attached to a brace in which case coverage is governed by the brace/orthotic benefit in the Act �1861(s)(9) with additional guidance in the Medicare Benefit Policy Manual (Internet-only Pub. 100-2, Chapter 15, Section 130), the Medicare Claims Processing Manual (Internet-only Pub. 100-4, Chapter 20, various sections) and the DME MAC LCD and related policy article entitled Orthopedic Footwear.
  2. For persons with diabetes only, substitution of modification(s) of custom-molded or depth shoes instead of obtaining a pair(s) of inserts in any combination. Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled.

In other words, orthopedic shoes, inserts and modifications may only be billed when attached to a brace, in which case the shoes, inserts and/or modifications must be billed by the supplier billing the brace or as a substitute for inserts in beneficiaries entitled to therapeutic shoes and inserts by virtue of a diabetes diagnosis.

For additional information on the proper coding, coverage and documentation requirements for orthopedic shoes, inserts and modifications refer to the DME MAC local coverage determination and related policy article Orthopedic Shoes at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspxExternal Website.

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