Medicare coverage for custom orthotics for non-diabetics

I would also be very careful about using the KX modifier when billing orthoticcs. For Fee for service Medicare (and others) it means the orthotic is placed into a shoe, that is an integral part of a brace. For other insurance carriers it may meet with a rejection as unprocessable for a variety of reasons. One being that the carrier's system simply doesn't recognize the modifier. In other cases, it can only be used for PT/OT CPT codes, stipulating that the patient has met and or exceeded the treatment frequencies and you have documentation supporting additional treatment.

Thus billed with L3000 it may result in claim rejection due to HCPCS and modifier inconsistency.

Let me add this comment, Jenny. Everything Paul wrote is spot on. There are some narrow circumstances where Medicare does not cover as it would be statutorily non covered, but the secondary does cover foot orthotics. Case in point is Federal BCBS. You bill the L3000RTGY and L3000LTGY. GY means, the service is statutorily non covered. Then, Federal BCBS would process if the diagnoses are those that match their medical policy. In my area, we use Carefirst BCBS policy for Federal claims and this is what this link says when submitting claims "Medicare claims billed using a 'GY' modifier can be submitted directly to CareFirst without prior submission to Medicare. These claims are not impacted by the 30 day requirement and do not require the inclusion of a Medicare EOB" https://provider.carefirst.com/providers/claims/medicare-secondary.page

The following are examples of conditions for which orthotic foot inserts are considered medically necessary: • tenosynovitis • neuroma, ganglioneuroma • chronic arthritic pain • diabetic foot disease / ulcers (see Therapeutic Shoes for Individuals with Diabetes, Policy 1.02.015) • bunions • tendonitis, achilles tendonitis • plantar fasciitis with or without heel spur • tarsal tunnel. The following are examples of conditions for which orthotic foot inserts are considered not medically necessary: • calluses • corns • fallen arches • flat feet The following are examples of non-covered items which are not considered to be orthotic foot inserts: • arch supports, over-the-counter • external lifts, such as elevated heels which are part of a shoe • footwear • items required for special interest activities or employment not considered to be routine daily living activities (e.g., running shoes, braces, etc.) • items that are primarily intended to assist in sports activities • items usually stocked by neighborhood pharmacies • disposable items • vasco heel cups

Jenny, Thank you for asking this most interesting question. It opens up the more important question of can we use the A shoe codes on non diabetics. And so for now, lets initially skip looking at the ICD10 codes you provided.

Let us first research the therapeutic shoe insert codes:

If one were to look at the therapeutic shoe insert codes A5512-A5514, one needs to ask one simple question, "What do they all have in common? All of these HCPCS codes state that they are "for diabetics only".

Thus these codes (A5500-A5514) would be in appropriately billed for patients who are not non-diabetic. This even if the non diabetic patient has the same profound amount of neuropathy as the diabetic patient and the same or equivalent medical necessity

You then asked about foot orthotic codes and whether your ICD10 codes would be the correct diagnosis codes to use for the appropriate custom made L coded foot orthotics (L3000-L3030).

For Fee for Service Medicare (FFS), the HCPCS codes for foot orthotics are found under the orthopedic footwear LCD. Reviewing this policy, one quickly understands that foot orthotics, no matter how medically necessary they are, are not typically ever covered under FFS. The one exception is when the shoe(s) into which the orthotics are placed is/are attached to a leg brace (the exact words are.. the shoes are an integral part of a brace-think Forrest Gump).

The ICD10 codes codes don't tell whether or not there is a leg bracing system attaching to the shoe. That attestation would need to be designated by the KX modifier after the chosen L code. Since in 40 years I only used the KX modifier on two patients, I will go out on a limb and state that the ICD10 codes, again under FFS Medicare don't really matter, but the lack of the KX does! Using the KX modifier when the shoe into which the orthotic device is placed does not have a brace, would be fraud!

As for Medicare Advantage plans, if they state that they follow CMS and Medicare policy guidelines, same story. If they do have their own LCD (and many do) then you would need to dig a bit deeper into the policy in order to determine the exact coverage terms for custom foot orthotics.

The same is true for state Medicaid Plans and/or private insurance.

While all that sounds like a nice tidy package, there is some grey with some Medicaid, Medicare Advantage and private third party payers. That is, some plans have lengthy plans with conflicting language. That is, one part of the policy provides coverage terms and the other defers to Medicare. This can make even the smartest office manager want to pull their hair out.

To avoid confusion, it may be best to call the plan prior to providing service or have the plan send you a letter of further explanation to reference moving forward, in order to determine if there is coverage and if so the exact terms of coverage.

I hope that answers your question.