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LCD for Orthopedic Footwear (L27220)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

17003

Contractor Type

DME MAC


LCD Information

LCD ID Number

L27220

LCD Title

Orthopedic Footwear

Contractor's Determination Number

ORFW

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2008 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

Illinois
Indiana
Kentucky
Michigan
Minnesota
Ohio
Wisconsin 

Oversight Region

Region V

DME Region LCD Covers

Jurisdiction B

Original Determination Effective Date

For services performed on or after 01/01/1995

Original Determination Ending Date

Not applicable

Revision Effective Date 

For services performed on or after 10/01/2009

Revision Ending Date

Not applicable

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.


Coding Information

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

Revenue Codes:

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

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.
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit
KX - Requirements specified in the medical policy have been met
LT - Left side
RT - Right side

HCPCS CODES:

HCPCSDescription
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:

ICD-9Description
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

Not applicable

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.

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, 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

Not applicable

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

Not applicable

Start Date of Comment Period

Not applicable

End Date of Comment Period

Not applicable

Start Date of Notice Period

01/01/1995

Revision History Number

007

Revision History Explanation

Revision Effective Date: 10/01/2009
HCPCS CODES AND MODIFIERS:
Added: GY modifier
Revised: KX modifier
DOCUMENTATION REQUIREMENTS:
Added: GY modifier instructions

3/1/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC National Government Services (17003) LCD L27220 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).

Revison 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.

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. 

Reason for Change

Not applicable

Last Reviewed On Date 

Not applicable

Related Documents

Article(s)

A47239 - Orthopedic Footwear - Policy Article - Effective October 2009

LCD Attachments

There are no attachments for this LCD


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Last Modified: 12/30/2010