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:
| HCPCS | 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 |
| 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-9 | Description |
| 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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