Orthotic coding for medicare

cmartin_333

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Look for the type of orthotic in your hcpcs book. Most of them begins with the letter l. Hope this helps.:):)
 

TammyHF

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HCPC L3000 through L3030 for custom orthotics which are not covered by Medicare unless it is part of a medically necessary brace. Since they are not cover by Medicare they would need to be submitted with a GY modifier showing that the custom orthotics are statutorily excluded. If the shoe insert is for a diabetic and meet the guidelines for a diabetic insert then the HCPCP code will be A5512 or A5513 will need KX, LT, and RT modifier.
 

SienTC1720

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Rutland, VT
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HCPC L3000 through L3030 for custom orthotics which are not covered by Medicare unless it is part of a medically necessary brace. Since they are not cover by Medicare they would need to be submitted with a GY modifier showing that the custom orthotics are statutorily excluded. If the shoe insert is for a diabetic and meet the guidelines for a diabetic insert then the HCPCP code will be A5512 or A5513 will need KX, LT, and RT modifier.
Could you provide the location in the claims manual where this policy is located?
 

podcoder70

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Could you provide the location in the claims manual where this policy is located?
I cannot speak to the "claims manual" but here is the link to the Local Coverage Article:
This is where it states:
Inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030 etc) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. This is something rarely seen.

The only reason you would bill L3000 to Medicare is if the patient insists, or if they have a secondary coverage that is NOT a supplement to Medicare. Such as an insurance plan that came from the employer they retired from. In some cases, very few, but some, these "secondary" payers will pay for the orthotic even though Medicare does not. If this is the scenario, you would need to bill the GY modifier so that when Medicare denies it you get a "PR" denial rather than "not covered and denied", then you cannot bill the patient. The GY modifier tells Medicare you know they are not covered and that you have notified the patient.
 
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