Orthopedic Footwear - Policy Article

Revision Effective Date: 11/01/2023
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner.” as clarification


04/03/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 11/01/2023
MODIFIERS:
Added: Statement, “When billing for a shoe replacement or shoe transfer that is an integral part of a leg brace, a KX modifier must be added to the code.”


09/28/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: L5220 to the list of partial foot or lower extremity prosthesis HCPCS codes that will result in orthopedic shoes denial when the shoes are put on over the prosthesis
MODIFIERS:
Added: LT and RT modifiers
Removed: “code (specific to the 5th digit)”
Added: “code(s) to the highest level of specificity”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Added: L5220 to the list of other types of leg prostheses that must not be used with HCPCS code L3250


05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: HCPCS code L3000 to noncovered statement, previously omitted in error


03/11/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
 Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
Removed
: Therapeutic Shoes for Persons with Diabetes codes, leaving reference to the policy

 REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
 Added: Section and related information based on Final Rule 1713
 CODING GUIDELINES:
 Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
Removed
: Therapeutic Shoes for Persons with Diabetes codes, leaving reference to the policy
 ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
 Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
 ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
 Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019

CODING GUIDELINES:
 Revised: RT and/or LT modifier instructions
 ICD-10 CODES THAT ARE COVERED:
 Added: All diagnosis codes formerly listed in the LCD
 ICD-10 CODES THAT ARE NOT COVERED:
 Added: Notation excluding all unlisted diagnosis codes from coverage


02/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Replacement order for heel or sole information and Modifiers requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.