Podiatry Coding & Billing Alert

If you don't keep orthotic types like replicate molding,direct molding, and pre-molded straight -- and attach the appropriate diagnosis code, you could be kicking yourself when the EOB turns up no pay.

Instead, follow this step-by-step guide to landing the correct orthotic code combo to net your podiatrist the payment he ethically deserves.

Select the appropriate HCPCS code for the orthotic from the section titled Orthotics, Foot (Orthopedic Shoes), Insert, Removable, Molded to Patient Model. Pay attention to whether the insert is custom-molded or pre-molded. Use that detail to choose between these categories:

You may bill for each foot. Most insurance companies prefer two line items: for instance, L3000-LT (Left side) and L3000-RT (Right side), says Hoda Henein, CHBME, CPL, president and CEO, Active Management in College Point, N.Y.

Choosing the right L code can be confusing. To succeed, look to whether the orthotic was molded from a replica or image or formed directly to the patient's foot. You would use L3000, for instance, when the podiatrist molds an insert to a replica or electronic image of the patient's foot, while you would report L3030 when the podiatrist is molding the insert directly to a patient's foot, explains Meredith Hughes, CPC, CHC, associate consultant with Acevedo Consulting in Delray Beach, Fla.

Look for documentation that clearly describes that a patient's foot was actually used during the creation of the insert when reporting L3030, advises Hughes. Don't rely on use of the word "molded," since that can mean either to a replica or to the patient's foot.

Tip: Consider creating a template that allows the podiatrist to mark which model was used for the creation of the insert, such as the foot, a replica, or an electronic image, suggests Hughes.

Watch out: Steer clear of other HCPCS codes in the L30xx section which superficially appear to apply, but which are intended for use within leg braces, such as L3031 (Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each), states the Washington State Podiatric Medical Association (WSPMA) at www.wspma.org/resources/orthotic_coding_suggestions.pdf.

Listen up: While there is no pre-determined frequency limit, insurers "might question L codes done more than once a year," says Henein.

Unlike with diabetic shoes and inserts, you can add a casting code to represent the podiatrist's work in conjunction with codes from the L30xx series. Report 29799 (Unlisted procedure, casting or strapping) for the casting procedure for custom-made orthotics such as L3000, L3020, or L3030, says Henein. Most insurance companies prefer two line items for 29799 as well, 29799- LT and 29799-RT.

Few payers may reimburse for the casting work, notes Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va., but reporting 29799 may be worth a try.

Remember: Replacement casts are billable, even within the surgical procedure's global period, adds Hughes. Consider reporting 29799 again for the replacement work, when applicable.

Warning: Whether reporting an original or replacement cast, most payers will not accept a supply code, such as A4580 (Cast supplies [e.g. plaster]) at the same time as the casting code (29799), indicates the WSPMA orthotic coding guide.

Lastly, in addition to the orthotic and casting code,include the appropriate diagnosis code for the foot condition on the claim form.

Example: Patient may require plaster or fiberglass casts for conditions such as:

• plantar fasciitis (728.71)

• pronation (736.79)

• metatarsus adductus (754.53).

Don't count on Medicare coverage of custom orthotics.

CMS stance: "Functional orthotic devices of this type (HCPCS L3000-L3030) are only covered if they are an integral part of a shoe which is permanently attached to a leg brace. Such instances are rare, and will most typically be provided by an orthotist; not by a podiatrist," states the WSPMA orthotic coding guide.

Tip: If a patient asks you to bill his functional orthotic devices to Medicare, submit the claim with modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit Medicare benefit or, for non-Medicare insurers, is not a contract benefit) appended to the code, indicating that you know this is a non-coveredservice, suggests the WSPMA guide.

When it comes to private insurer, who may cover the L30xx series codes, diagnoses such as diabetes (250.xx) or loss of protective sensation (LOPS) aren't a guarantee of coverage, points out Henein.

Best advice: Inquire with individual insurers about custom orthotic coverage prior to service. Ask the payer for its allowable amount or request an authorization for a set price. Make sure the patient knows that whatever costs exceed those limits are the patient's responsibility.