sd sd sd sd sd sd sd sd

Blog

Jun 17

Written by: Larry Huppin, DPM
6/17/2010 10:43 AM

I had a client call this morning asking about Medicare coverage for foot orthotics. She had informed a patient that Medicare would not cover her orthotics. The patient then called Medicare and was told by the person she spoke with that Medicare does cover them.

The short answer is Medicare does not cover foot orthoses

Custom foot orthoses are billed under HCPCS Code L3000. In some situations they are billed as L3010 and L3020. Here are the Medicare HCPCS codes for foot orthoses.

Medicare HCPCS Codes for Custom Foot Orthoses

  • L3000: Foot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each
  • L3010 Foot, insert, removable, molded to patient model, longitudinal arch support...
  • L3020 Foot, insert, removable, molded to patient model, longitudinal/ metatarsal ...
Medicare does not pay for these codes and thus does not cover foot orthotics. They are absolutely never a covered service.

Patients can get confused because they will be told by poorly trained Medicare personnel that foot orthotics are covered. The reason for this is that there is one situation where these codes are paid by Medicare. That situation is when the orthoses is an integral part of a shoe that is attached to a leg brace. That means the brace is attached permanently to the shoe. We are talking about the kind of brace that FDR wore. In the picture at left you can see the braces attached to the shoe under his pant leg.  At far left are the actual braces attached to his shoes.   So Medicare might pay for foot orthoses IF your patient is wearing these.  

The other thing that is confusing to patients (and to some doctors) is that Medicare does cover soft insoles for diabetic patients under the Medicare Therapeutic Shoe Bill. These are not functional orthoses, simply soft accommodative insoles that compress quickly and provide less control then most good prefabricated orthoses. Here is the HCPCS code:
  • A5513: For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher), includes arch filler and other shaping material, custom fabricated, each
In summary, patients are sometimes getting bad information from Medicare regarding orthotic coverage.  It is our responsibilty to educate them as to the reality of the situation.

Tags:

10 comments so far...

Re: Does Medicare Cover Foot Orthotics?

Thank you for the information. The explanation given above is the exact scenario I am going through for my mom. She has Humana Gold Plus which I have been told follows Medicare's guidelines by the facility that makes the functional orthotics and say HGP will not pay even though she has been given an approval/referral. However when I call Humana, they say she is good to go and they will pay! I've gone back and forth a couple of times and have even gotten her primary Dr's office to assist, who was also told the same. It has been incredibly frustrating! At the end of the day, she needs them so we will have to pay the $350.00.

By Charlene on   11/27/2013 12:58 PM

Re: Does Medicare Cover Foot Orthotics?

Thank you for the informative article.
But if I need a custom foot orthotic (ucb type) to help me walk properly after having had a TKR isn't it discriminating against me because I do not have diabetes?

By LaBerta E Finck on   3/5/2012 3:07 PM

Re: Does Medicare Cover Foot Orthotics?

We just found out that orthotics are not covered. We happened to beadding the KX modifier and they were getting paid. We are issueing refunds to Medicare as we speak. A question we have though, are any of the L3000 codes supposed to be covered? i.e. L3100. Also, we are puzzled as to why they don't require a certain diagnosis rather than cover across the board with the KX modifier. Any help would be very much appreciated!!!
Thank you.

By Chris M. on   3/5/2012 3:07 PM

Re: Does Medicare Cover Foot Orthotics?

Medicare does not cover custom foot orthotics (L-codes) under any situation. No exceptions. They do not cover with the KX modifier. You getting paid does not mean that they are covered. If you are paid, you have a responsibility to refund.

All orthotic payments are the responsibility of the patient. Unless requested by the patient you do not have to bill Medicare.

By LH1000 on   3/5/2012 3:06 PM

Re: Does Medicare Cover Foot Orthotics?

the information below is from CMS website and there are some conditions in addtion to the others when foot insert are covered (L3010) see explanation below. Therapeutic Shoes or Inserts: Medicare covers therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease. The doctor who treats your diabetes must certify your need for therapeutic shoes or inserts. The shoes and inserts must be prescribed by a podiatrist or other qualified doctor and provided by a podiatrist, orthotist, prosthetist, or pedorthist. Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year. Shoe modifications may be substituted for inserts. The fitting of the shoes or inserts is covered in the Medicare payment for the shoes.

By jose borges on   5/3/2012 7:23 AM

Re: Does Medicare Cover Foot Orthotics?

Thanks for the input Jose, but you are not correct.

Medicare will pay for soft accommodative insoles for diabetic patients. They do not pay for functional orthotics nor do they pay for any L-code orthosis (L3000, L3010, L3020, etc). They have set up some special A-codes for the inserts they pay for, but again, these are just soft cushions, not orthotics.

By LH1000 on   5/3/2012 7:27 AM

Re: Does Medicare Cover Foot Orthotics?

Thanks for this article!! Tricky tricky! To the user below, KX means it is part of the leg brace if you read the guidelines, GY is not part of brace. I had denials as well. Im just thankful they have secondaries to pick up!

By Briana on   11/27/2013 12:58 PM

Re: Does Medicare Cover Foot Orthotics?

Medicare will cover shoes with code A5500 witch is Diabetic shoes, men's or wemen's. So they will cover shoe and inserts, but only for diabetics.

By Jennifer on   11/27/2013 12:58 PM

Re: Does Medicare Cover Foot Orthotics?

Thank you for posting this. I have my own Pedorthic facility and I am going through this daily. Patients swear that the person at Medicare told them these kind of orthoses are covered. Today I called while the patient was standing at the counter. The Medicare person had no idea what I was talking about. He asked me if this is usually covered, than he said I should read the LCD on L-codes and than he finally said that Medicare may consider payment.
Here is how I handle this for the last few month: the patient will sign and receive an ABN (Advance Beneficiary Notice of Noncoverage). Signing this the patient states that he/she understands that this may not be covered. I will have the patient pay in advance ! The orthoses will then be billed to Medicare. IF (!) Medicare for some very, very strange reason would decide to pay for the claim, the patient will receive the money back.

By K.Reichl on   11/27/2013 12:59 PM

Re: Does Medicare Cover Foot Orthotics?

If you bill Medicare for the orthotics you MUST use a GY modifier. This tells Medicare that "I know this is not covered, but my patient insists that I bill it anyway. please deny this item."If you do not use the GY modifier and Medicare pays for the orthotics, then you MUST refund this money to Medicare. It is not legal to keep that money. It is not yours. One more time. IN ABSOLUTELY NO SITUATION DOES MEDICARE EVER PAY FOR L-CODE FOOT ORTHOTICS. If they ever do pay it is a mistake and likely due to poor coding. It is not legal to keep that money. If Medicare patients want orthotics, they must pay for them out of pocket. No exceptions. Ever.

You should NEVER give that money back to the patient even if Medicare pays. It is not yours to give. Send it back to Medicare.

So, let's just finish this thread. It is really, really simple. MEDICARE DOES NOT PAY FOR L-CODE FOOT ORTHOTICS. NEVER. NOT FOR ANY REASON.

By LH1000 on   11/27/2013 1:02 PM

Your name:
Title:
Comment:
Security Code
Enter the code shown above in the box below
Add Comment    Cancel  
Home   |   About   |   Products   |   Education   |   Consultation   |   Client Services   |   E-Journal    |   Blog