Monday, April 17, 2017

Orthopedic Footwear CPT code list

HCPCS CODES


Group 1 Codes:

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, PREFABRICATED, OFF-THE-SHELF

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, PREFABRICATED, OFF-THE-SHELF, 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

Coverage Guidance
Coverage Indications, Limitations, 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 local coverage determination, the criteria for "reasonable and necessary" are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) 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 reasonable and 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 a beneficiary with a partial foot amputation (described by the diagnosis codes listed in the table below). Claims for prosthetic shoes for other diagnosis codes will be denied as not medically necessary.


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.
N/A

Revenue Codes:
Contractors may 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.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: 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 

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