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Orthopedic and Therapeutic Footwear

Date: 06-08-2012

  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Definitions
  • Overview

    Therapeutic footwear is used to prevent diabetic ulcers. Orthopedic footwear is used by individuals with structural conditions of the foot.

    Eligible Providers

  • • Medical suppliers
  • • Indian Health Services
  • • Federally Qualified Health Center
  • • Rural Health Clinic
  • Therapeutic shoes, modifications and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of diabetic shoes and inserts.

    Orthopedic shoes, modifications and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of orthopedic shoes and inserts

    All shoes, modifications and inserts must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist or prosthetist.

    TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.

    Eligible Recipients

    Orthotics are covered for all eligible MHCP recipients.

    Covered Services

    Therapeutic Shoes, Modifications and Inserts for Persons with Diabetes

    Codes: A5500-A5501 (therapeutic shoes), A5503-A5507 (modifications to therapeutic shoes), A5510-A5513 (inserts for therapeutic shoes)

    Custom-made or stock therapeutic shoes and modifications to therapeutic shoes are covered for MHCP recipient with diagnosed diabetes and one or more of the following conditions:

  • • Previous amputation of the other foot, or part of either foot
  • • History of foot ulceration of either foot
  • • History of pre-ulcerative calluses of either foot
  • • Peripheral neuropathy of either foot
  • • Foot deformity of either foot
  • • Poor circulation of either foot
  • Inserts for therapeutic shoes, whether custom-made or stock, are covered only when the recipient has covered therapeutic shoes.

    2 pair of therapeutic shoes, modifications and inserts are covered without authorization in a calendar year. They can be dispensed at the same time, or at different times.

    MHCP uses the coding guidelines for therapeutic shoes, modifications and inserts that are found in the Medicare Local Coverage Article for Therapeutic Shoes for Persons with Diabetes for Medicare’s DME MAC contractor for the state of Minnesota.

    Orthopedic Shoes and Inserts

    Codes: L3000-L3031 (custom inserts), L3040-L3060 (premolded, removable arch supports), L3070-L3100 (non-removable arch supports), L3140-L3150 (abduction and rotation bars), L3224-L3253 (orthopedic footwear), L3300 – L3595 (additions and modifications to orthopedic shoes), L3600-L3640 (transfer of orthotic), L3649

    MHCP will cover custom-made orthopedic shoes, modifications and inserts when the shoe is an integral part of a leg brace, or for recipients with one or more of the following medical conditions:

  • • Foot deformity accompanied by pain
  • • Plantar faciitis
  • • Calcaneal bursitis (acute or chronic)
  • • Calcaneal spurs
  • • Inflammatory conditions such as submetatarsal bursitis, synovial cyst or plantar fascial fibromatosis
  • • Medial osteoarthritis of the knee
  • • Musculoskeletal / arthropathic deformities
  • • Neurologically impaired feet
  • • Vascular conditions
  • • Hallus valgus deformities in children
  • MHCP will cover stock orthopedic shoes for recipients only if the shoes are an integral part of a covered leg brace and if they are medically necessary for the proper functioning of the leg brace.

    MHCP will cover stock inserts only for use in covered orthopedic shoes.

    1 pair of orthopedic shoes and 2 pair of inserts are covered without authorization in a calendar year.

    Foot Pressure Off-Loading Device

    Code: A9283
    A foot pressure off-loading device is covered for pressure reduction for existing pressure ulcers on the foot.

    Noncovered Services

  • • A prosthetic or orthotic device for which Medicare has denied the claim as not medically necessary
  • • A device whose primary purpose is to serve as a convenience to a person caring for the recipient
  • • A device that serves to address social and environmental factors and that does not directly address the recipient’s physical or mental health
  • • Deluxe features of therapeutic shoes.
  • • A device that is supplied to the recipient by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device.
  • Authorization

    Authorization for orthopedic footwear is required only when a second or subsequent pair of orthopedic shoes or a third or subsequent pair of inserts is required in any calendar year. Authorization will be granted when the items are needed because of a change in the recipient’s medical condition or size which requires replacement.

    Authorization for therapeutic footwear is required only when a 3rd pair or subsequent pair of therapeutic shoes or inserts is required in any calendar year. Authorization will be granted when the items are needed because of a change in the recipient’s medical condition or size which requires replacement

    Submit authorization requests through MN-ITS (Authorization Request 278). Fax the MN-ITS response with the required documentation, physician’s orders and appropriate additional information to the medical review agent. Write the MN-ITS Authorization Request number on each page of each document.

  • • Document the reason that the shoes or inserts require replacement.
  • • MHCP will not authorize more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs).
  • • Each line will be approved or denied, with the allowed dollar amount listed if approved.
  • Billing

  • • MHCP will not pay claims for more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs) except that 4 units of therapeutic shoes, modifications and inserts for recipients with diabetes may be dispensed and billed on the same date of service.
  • • When billing labor for repairs, specify the number of units and the hourly rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.
  • Definitions

    Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.

    Custom-made: Made for a specific patient from his or her individual measurements and/or pattern

    Inserts: Artificial devices which are placed in a shoe to assist in restoring or maintaining normal alignment of the foot

    Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.

    Prosthetic: An artificial device, as defined by Medicare, to replace a missing or nonfunctional body part

    Stock: Off the shelf items that are not fabricated to an individual’s specifications. They may be adjusted or altered to meet the recipient’s needs, but are not made specifically for the recipient.

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