RETIRED - Correct Coding - Medicare Coverage for Shoes - JD DME

Joint DME MAC Bulletin Article

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, other than shoes furnished pursuant to section 1861(s)(12). 

SSA 1861(s)(12) describes coverage for, "extra-depth shoes with inserts or custom molded shoes with inserts for an individual with diabetes" when certain specified requirements are met. Reimbursement is available for shoes used by beneficiaries with diabetes when the applicable coverage requirements are met. The Therapeutic Shoes for Persons with Diabetes (TSD) Local Coverage Determination (LCD) and related Policy Article discuss these payment rules in detail. 

In addition to TSD, payment may be possible for shoes that are an integral component of a brace. 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. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace.  (Emphasis added). 

These brace-related shoes are referred to as orthopedic footwear (ORF). Note that only the supplier of the brace may bill for payment for ORF in conjunction with claims for payment of the qualifying brace. Separate payment to a different supplier for shoes that are an integral component of a brace or for inserts and modifications to those shoes is not allowed. The Orthopedic Footwear LCD and related Policy Article address the applicable payment rules for these items.

There are situations where a beneficiary may qualify for both a diabetic shoe and a leg brace.  CMS Internet Only Manual 100-02, Chapter 15, Section 140 says:

In situations in which an individual qualifies for both diabetic shoes and a leg brace, these items are covered separately. 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.

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.

Only HCPCS A-codes are used for TSD and related items.  Only L-codes are used for ORF.  Both the TSD and ORF related Policy Articles address these points.

• From TSD Policy Article
  • Codes for inserts or modifications (A5503 – A5508, A5510, A5512, A5513) may only be used for items related to diabetic shoes (A5500, A5501). They must not be used for items related to footwear coded with codes L3215 - L3253. Inserts and modifications used with L-coded footwear must be coded using L codes (L3000 - L3649).*
• From ORF Policy Article
  • Shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes (A5500-A5511) are used for footwear provided under this benefit. See the medical policy on Therapeutic Shoes for Persons with Diabetes for details.*
  • Depth-inlay or custom molded shoes for diabetics (A5500-A5501) and related inserts and modifications (A5503-A5511) are billed using these A-codes whether or not the shoe is an integral part of a brace. 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. Oxford shoes that are not part of a leg brace must be billed with codes L3215 or L3219 without a KX modifier.
  • Other shoes (e.g., high top, depth inlay or custom shoes for non-diabetics, etc.) that are an integral part of a brace are billed using code L3649 with a KX modifier. 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.  HCPCS code A5507 must not be used to bill for this service.  See Orthopedic Footwear section (below) for additional information.

Orthopedic Footwear

From the Nonmedical Necessity Coverage and Payment Rules section of the ORF Policy article:

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. Other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) 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. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded.

According to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements, are covered only when the shoe is an integral part of a brace. 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. Shoes which are billed separately (i.e., not as part of a brace) will be denied as noncovered. 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.

Refer to the LCDs, related Policy articles and the Supplier Manual for additional information about coverage, coding and documentation for these items.

For questions about correct coding, contact the Pricing, Data Analysis and Coding Contractor (PDAC) Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form.

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