Podiatry Coding & Billing Alert

Ace this quiz to keep your orthotic and specialty shoe skills sharp!

Question 1 scenario: A patient visited a podiatrist due to persistent pain in their right foot following a fall two weeks prior. Despite previous X-rays showing no fracture, the podiatrist conducted further X-rays and an ultrasound. These revealed a compression fracture in the first metatarsal, accompanied by swelling. The patient was fitted with a surgical shoe and given instructions for its use. They are scheduled for a follow-up appointment in two weeks.

How should you code for the surgical shoe?

Answer: You will need to consult your HCPCS Level II book to code for the surgical shoe. For this item, you should report L3260 (Surgical boot/shoe, each).

Note: When you are billing for a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) code — in this case L3260 — most insurance companies require you to submit a separate claim. “The reasoning for this is the place of service [POS] will be 12 [Home] as opposed to 11 [Office] for your other charges,” says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia.

“The claim also requires you to enter the ordering provider. If the patient is under Medicare, the KX modifier [Requirements specified in the medical policy have been met] must be used to indicate that the supplier has ensured the coverage criteria for the DMEPOS billed is met, and that documentation does exist to support the medical necessity of the item. Documentation must be available upon request,” Jordan explains.

Question 2: Are there any circumstances where you can still be reimbursed for custom orthotics even if a patient never picks them up?

Answer: In situations where a patient doesn’t pick up custom-fitted durable medical equipment (DME) such as orthotics, Medicare allows payment in three specific circumstances:

1. Death of the beneficiary

2. Cancellation of the order by the beneficiary

3. A change in medical necessity for the item such that it is no longer suitable for the beneficiary’s medical condition.

Payment tip: To prevent patients from leaving you with the bill, you may want to consider having them pay at the time of casting instead. For some Medicaid payers that prefer orthotics billing at casting time, use codes 29799 (Unlisted procedure, casting or strapping) or S0395 (Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic), with RT (Right) and LT (Left) modifiers as needed, to recover some costs. Concurrently, if allowed, take a deposit from patients with commercial plans to offset costs in case of no-shows. If orthotic payment is denied, refund the deposit minus any patient contract obligations.

Question 3: How can your practice always ensure that you meet the documentation requirements when reporting orthopedic footwear for a patient?

Answer: It is crucial for the payer to comprehend and concur with the medical necessity of the visit, regardless of whether it’s an office visit with a podiatrist or an orthotics fitting with a pedorthist. To avoid denials, be sure your documentation includes all the following required pieces of information:

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

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

• Patient’s name or Medicare beneficiary identifier (MBI)
• Order date
• General description of the item
• Quantity to be dispensed, if applicable
• Treating practitioner name or national provider identifier (NPI)
• Treating practitioner’s signature

Question 4: Can the prescribing physician also be the supplier of orthotic shoes and/or inserts?

Answer: The prescribing professional can also be the provider of shoes and/or custom-made orthotics. A lot of podiatry clinics will conduct the foot exam, write the prescription for the shoes, and then ask the patient to come back once the shoes are delivered to make sure they fit properly.

However, make sure you understand the roles of each person when it comes to reporting therapeutic shoes and inserts:

• The prescribing practitioner writes the order for the therapeutic shoes, modifications, and inserts. The prescribing practitioner must be knowledgeable in the fitting of the custom shoes and inserts. They may be a podiatrist, medical doctor (MD), doctor of osteopathic medicine (DO), physician’s assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The prescribing practitioner may also be the supplier.
• The supplier furnishes the shoes, modifications, and/or inserts to the patient. The supplier may be a podiatrist, pedorthist, orthotist, prosthetist, or another qualified individual. The prescribing practitioner may also be the supplier.

Question 5 scenario: Your podiatrist has been treating a patient with an ankle wound repeatedly. The patient has been coming in weekly for wound care. During the patient's last visit, the podiatrist decided to apply an Unna boot to help with the healing process.

Since you are responsible for coding the claim, is there any particular wording that should appear in the medical notes that would also tell the payer an Unna boot was applied?  

Answer: Yes, in the podiatrist’s note, they must state “multilayer compression wrap applied” versus making the statement “Unna boot applied.” An Unna boot is also known as a multilayer compression wrap. Code 29580 (Strapping; Unna boot) falls under the “strapping” category. An Unna boot is a product that has no stretch or flexibility and has a layer of zinc that assists in the healing process. It is usually followed with Coban or ACE wrap due to the sticky nature. As such, it is not a multilayer compression wrap.

On the other hand, If the doctor truly did apply a multilayer compression wrap to the patient’s lower ankle, that would be coded as 29581 (Application of multi-layer compression system; leg (below knee), including ankle and foot) and the documentation should clearly state how many layers were applied (usually more than three).

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC