Are shoes eligible for Medicare reimbursement?
There are no other categories of shoes that are eligible for Medicare reimbursement. Different sets of HCPCS codes are used to identify the shoes, modifications, and inserts that may be eligible for payment. Suppliers must be sure to use the correct codes for each group of products.
How do you bill for therapeutic shoes for people with diabetes?
See the medical policy on Therapeutic Shoes for Persons with Diabetes for coverage, documentation, and additional coding guidelines. Oxford shoes that are an integral part of a brace are billed using codes L3224 or L3225 with a KX modifier. For these codes, one unit of service is each shoe.
How do I Bill for shoes that are not an integral part?
Other shoes that are not an integral part of a brace must be billed using codes L3216, L3217, L3221, L3222, L3230, L3251-L3253, or L3649 without a KX modifier. *Note: Transferring or otherwise attaching a TSD to a brace is NOT considered a modification to the TSD.
What modifiers should I use when billing my Shoes?
The right (RT) and/or left (LT) modifiers must be used when billing shoes, inserts, or modifications.
Are diabetic shoes considered DME?
Claims for therapeutic shoes for diabetics are processed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs). Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics, but a separate category of coverage under Medicare Part B.
Does Medicare cover a surgical shoe?
Medicare will only cover your therapeutic shoes if your doctors and suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren't enrolled, Medicare won't pay the claims they submit.
How do you write a prescription for diabetic shoes?
1. Detailed written order (prescription). Include space for prescribing shoes (A5500), the quantity of custom inserts (A5513) or quantity of prefab heat-moldable inserts (A5512). This must be dated within six months of dispensing shoes.
Are diabetic shoes covered by insurance?
No cost to you! Medicare and most insurance companies will pay for one pair of diabetic shoes and three custom molded inserts per calendar year.
What is the CPT code for post op shoe?
There is only one HCPCS code that is appropriate for a post-op shoe (L3260, surgical shoe, each). Like orthotics, this item is a statutorily excluded benefit by Medicare and DME and will not be covered under any circumstances.
Will Medicare pay for my orthopedic shoes?
Medicare covers orthopedic shoes if they're a necessary part of a leg brace. The amount you must pay for health care or prescriptions before Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your other insurance begins to pay.
Does Medicare cover L3020?
Response: Custom functional foot orthotic devices (e.g., L3000, L3020, L3030) are not covered by Medicare for non-diabetic patients...or for diabetic patients. Functional foot orthoses, as we know, understand, and use them, are statutorily NOT covered by Medicare.
Are SAS shoes covered by Medicare?
The SAS Tripad® construction and SAS Supersoft® lightweight sole will keep you supported and comfortable through every step of your day. These shoes are also Medicare and Diabetic approved, so you know they meet the highest standards of support and comfort. These shoes are Medicare and Diabetic Approved shoes.
What is special about diabetic shoes?
Diabetic shoes decrease the risk of diabetic foot ulcers and thereby reduce amputations. They provide support and protection while minimizing pressure points on the feet. They also have extra depth to accommodate diabetic inserts. There are many styles to choose from, and the shoes look much like any other shoe.
Does Social Security pay for diabetic shoes?
Therapeutic Shoes and inserts are covered under the Therapeutic Shoes for Individuals with Diabetes benefit (Social Security Act §1861(s)(12)).
What do diabetic shoes cost?
$50-$200 per pairHow Much Do Diabetic Shoes Cost? Diabetic shoes can be costly because they're specialty shoes and need to be custom-fitted for your feet. On average, diabetic shoes can range in cost from $50-$200 per pair.
Does Medicare cover A5512?
Medicare allows coverage for a single L5000. If patient has diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts.
What is Medicare approved amount?
Medicare-Approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B.
What is original Medicare?
Your costs in Original Medicare. An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
What are therapeutic shoes?
Therapeutic shoes & inserts 1 One pair of custom-molded shoes and inserts 2 One pair of extra-depth shoes
Does Medicare cover therapeutic shoes?
Medicare will only cover your therapeutic shoes if your doctors and suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren't enrolled, Medicare won't pay the claims submitted by them. It's also important to ask your suppliers ...
Does Medicare cover custom molded shoes?
One pair of custom-molded shoes and inserts. One pair of extra-depth shoes. Medicare also covers: 2 additional pairs of inserts each calendar year for custom-molded shoes. 3 pairs of inserts each calendar year for extra-depth shoes. Medicare will cover shoe modifications instead of inserts.
Do suppliers have to accept assignment for therapeutic shoes?
It's also important to ask your suppliers if they participate in Medicare before you get therapeutic shoes. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren't "participating," they may choose not to accept assignment.
What is the code for Oxford shoes?
Oxford shoes that are an integral part of a brace are billed using codes L3224 or L3225 with a KX modifier. For these codes, one unit of service is each shoe. Oxford shoes that are not part of a leg brace must be billed with codes L3215 or L3219 without a KX modifier.
What is the code for a covered leg brace?
Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, L3225) are covered in these situations.
Can KX modifier be used on shoes?
A KX modifier must not be used in this situation. Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010-L5600) which is attached to the residual limb by other mechanisms because there is no Medicare benefit for these items.
Can diabetic shoes be covered by TSD?
Thus, the diabetic shoes may be covered if the requirements for this section are met, while the brace may be covered if the requirements of §130 (Braces Benefit) are met. (Emphasis added). This means that the supplier of the TSD may bill separately for TSD while a different supplier may bill for the associated brace.
Is TSD covered by CMS?
CMS Internet Only Manual 100-02, Chapter 15, Section 290.B states: Orthopedic shoes and other supportive devices for the feet generally are not covered.
Does Medicare cover shoes?
Medicare has limited coverage provisions for shoes used by beneficiaries. Section 1862 (a) (8) of the Social Security Act (SSA) says: [N]o payment may be made under part A or part B for any expenses incurred for items or services … where such expenses are for orthopedic shoes or other supportive devices for the feet, ...
Can a matching shoe be billed with a KX modifier?
A matching shoe which is not attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as noncovered because coverage is statutorily excluded. Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace.
Who is required to prescribe diabetic shoes?
The need for diabetic shoes must be certified by a physician who is a doctor of medicine or a doctor of osteopathy and who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care.
Who can fit diabetic shoes?
The footwear must be fitted and furnished by a podiatrist or other qualified individuals such as a pedorthist, an orthopedist, or a prosthetist. The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area.
Is diabetic shoe covered by Medicare?
Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics, but a separate category of coverage under Medicare Part B. Diabetic shoes are covered if the requirements as specified in this section concerning certification and prescription are fulfilled. In addition, this benefit provides for a pair of diabetic shoes even if only one foot suffers from diabetic foot disease. Each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected. Claims for therapeutic shoes for diabetics are processed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES 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 illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
ICD-10-CM Codes that Support Medical Necessity
The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the Non-Medical Necessity Coverage and Payment Rules section for other coverage criteria and payment information.
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 article does not apply to that Bill Type.
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 article, services reported under other Revenue Codes are equally subject to this coverage determination.
What percentage of Medicare payment does a supplier pay for assignment?
If your supplier accepts Assignment you pay 20% of the Medicare-approved amount, and the Part B Deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment:
What is Medicare approved amount?
Medicare-Approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B.
What is Medicare assignment?
assignment. An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. you pay 20% of the. Medicare-Approved Amount.
Does Medicare cover DME equipment?
You may be able to choose whether to rent or buy the equipment. Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare.
Who can not furnish diabetic shoes?
an orthotist, or a prosthetist. The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area. It is left to the discretion of each A/B MAC (B) to determine the meaning of “in the area.” 2
Who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care
physician who is a doctor of medicine or doctor of osteopathy who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care, as well as podiatrists or other qualified physicians knowledgeable in fitting diabetic shoes
