The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication to remind suppliers about the correct coding of products that may qualify for coverage under Medicare’s limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries.
To be eligible for coverage, such items must qualify in either:
- The benefit category for therapeutic shoes provisioned in the treatment of a diabetes-related condition(s) or
- The benefit category for leg braces (to which the shoes and related items would be considered for coverage as integral components of the leg brace).
The coding of the products for claims submitted for Medicare reimbursement depend upon the benefit category.
Social Security Act (SSA) section (§)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.
In addition to therapeutic shoes provisioned in the management an individual’s diabetes-related condition, payment may be possible for shoes, inserts, and shoe modifications that are an integral component of a brace (42 CFR §411.15(f)). The Centers for Medicare & Medicaid Services (CMS) Benefit Policy Manual (CMS Pub. 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 by the DME MACs.)
Section (§) 1862(a)(8) of the Social Security Act (SSA) reads:
[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).
Furthermore, SSA §1862(a)(13) specifically excludes treatment and devices for flat feet, subluxations of the foot, and routine foot care.
Shoes, inserts, and shoe modifications that are an integral component of a leg brace are referred to as orthopedic footwear (ORF). These shoes, inserts, and shoe modifications are only covered if they are an integral part of a covered leg brace that is described by HCPCS code L-1900, L-1920, L-1980, L-1990, L-2000, L-2005, L-2010, L-2020, L-2030, L-2050, L-2060, L-2080, or L-2090. In addition to being an integral component of the covered leg brace, these products must also be medically necessary for the proper functioning of the leg brace. When billing for ORF, the leg brace and ORF must be billed by the same supplier.
The use of shoes, inserts or shoe modifications must not be used on braces that fit inside a shoe. This is considered incorrect coding and is statutorily non-covered by Medicare.
There are situations where a beneficiary may qualify for both a diabetic shoe and a leg brace. The CMS Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 140 reads:
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 by the DME MACs.)
This means that the supplier of the therapeutic shoes provisioned in the treatment of a diabetes-related condition may bill separately for such shoes, while a different supplier may bill for the associated brace.
Different sets of Healthcare Common Procedure Coding System (HCPCS) codes are used to identify the shoes, modifications, and inserts that may be eligible for payment. The determination as to which HCPCS code(s) must be utilized depends on the benefit category within which the shoes, modifications, and inserts qualify for coverage. Suppliers must be sure to use the correct codes for each group of products. Only HCPCS A-codes are used for shoes and related items provisioned in the treatment of an individual’s diabetes-related condition(s). Only L-codes are used for ORF.
Transferring or otherwise attaching a therapeutic shoe (that is provisioned in the treatment of the diabetes-related condition) to a brace is not considered a modification to the therapeutic shoe. HCPCS code A-5507 must not be used to bill for this service (see the medical policy on Therapeutic Shoes for Persons with Diabetes for details).
The use of shoes, inserts, or shoe modifications are noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis which is attached to the residual limb by other mechanisms because there is no Medicare benefit for these items.
To read the complete coding revision, visit the CGS website.
