Podiatry Coding & Billing Alert

Question: I am having trouble coding a surgical shoe (HCPCS L3260). Codify is showing 0 units billable for $0.00. Is there any other code we would be able to use in its place? Or is there a modifier we can apply to the HCPCS code to allow for reimbursement?

AAPC Forum Participant

Answer: Medicare considers L3260 (Surgical boot/shoe, each) a noncovered code. Some “shoes, inserts, and modifications are covered in … selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers,” while some other “orthopedic footwear is covered under the leg, arm, back, and neck braces, and artificial legs, arms and eyes benefit (Social Security Act §1861(s)(9)),” according to Local Coverage Determination (LCD) A52481 (www.cms.gov/medicare-coverage-database/view/article. aspx?articleId=52481). So, you may be able to bill another kind of footwear with medical necessity, per the LCD.

However, as Medicare considers L3260 noncovered, you cannot recoup your expense. This means you should ask the patient to pay you directly for the item when you dispense it. The patient doesn’t have to sign an advance beneficiary notice (ABN) in order for you to collect payment. However, you can ask the patient to sign an ABN to verify that they are aware of their responsibility to pay you for the item.

Some patients might ask you to submit a claim for the surgical boot to Medicare so they can request coverage from a secondary insurer. If this occurs with one of your Medicare patients, you should append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit…) to L3260 before submitting the claim to indicate to Medicare that you are aware that you are requesting payment for a statutorily excluded service.