Podiatry Coding & Billing Alert

Hint: Covered Oxford shoes include L3224 and L3225.

In a recent webinar, Lisa Addison, provider outreach and education specialist at CGS, gave expert advice for how to report orthopedic footwear. This includes understanding the coverage requirements, which codes you should report, and what information to include in the medical documentation.

Editor’s note: This advice does not apply to shoes for diabetic patients, which is a separate policy.

Dig Into Orthopedic Footwear Coverage Requirements

Orthopedic footwear is covered under the leg, arm, back, and neck braces and artificial legs, arms, and eyes benefit, according to Addison. Shoes, inserts, and modifications will be covered in limited circumstances.

Orthopedic shoes and related modifications, inserts, and heel/sole replacements are covered only when

the shoe is an integral part of a brace, Addison added. Therefore, when a matching shoe is not attached to a brace, the items related to that shoe will be denied as noncovered.

“Oxford, high top, depth inlay or custom non-diabetic shoes are covered if they are an integral part of a covered brace and are medically necessary for the proper functioning of the brace,” Addison said. “Shoes incorporated into a brace must be billed by the same supplier billing for the brace.”

Pinpoint Shoes and Covered Leg Brace Codes

Covered Oxford shoes include codes L3224 (Orthopedic footwear, woman’s shoe, Oxford, used as an integral part of a brace (orthosis)) and L3225 (Orthopedic footwear, man’s shoe, Oxford, used as an integral part of a brace (orthosis)), per Addison.

The following required leg braces are also needed for L3224 and L3225 to be covered: Note: This is not an exhaustive list.

• L1900 (Ankle foot orthosis (AFO), spring wire, dorsiflexion assist calf band, custom-fabricated)
• L1920 (Ankle foot orthosis (AFO), single upright with static or adjustable stop (phelps or perlstein type), custom-fabricated)
• L1980 (Ankle foot orthosis (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar ‘BK’ orthosis), custom-fabricated)
• L1990 (Ankle foot orthosis (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar ‘BK’ orthosis), custom-fabricated)
• L2000 (Knee ankle foot orthosis (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthosis), custom-fabricated)

On the other hand, if the patient requires a different shoe than the Oxford type, Medicare will consider other shoes for coverage. Other shoes (e.g., high top, depth inlay or custom shoes for non-diabetics, etc.) are covered if they meet the following criteria, according to Addison:

• They are an integral part of a covered brace.
• They are medically necessary for the proper functioning of the brace.

You should bill these shoes with L3649 (Orthopedic shoe, modification, addition or transfer, not otherwise specified) and modifier KX (Requirements specified in the medical policy have been met) appended.

Don’t miss: When you bill L3649-KX, your claim must include a narrative description of the item provided, as well as a brief statement of the medical necessity for item. This information must be entered in the narrative field of the electronic claim.

Make Sure Documentation Requirements Are Met

When you report orthopedic footwear in your podiatry practice, you should always make sure that you meet the documentation requirements. These include the following:

• Prescription (order)
• Medical record information to support medical necessity
• Correct coding
• Proof of delivery

Standard written order: A standard written order (SWO) must be obtained by the supplier before submitting the claim. The SWO must include the following, according to Addison: