Thank you all for your responses to my question. The consensus is that
medicare will pay for a off the shelf shoe for the brace but not the
contralateral side. Custom shoes are only covered if the patient is
diabetic. The original question plus the replies follows:
I know I should know this (and I probably used to) but need an answer
asap. Looked through medicare LCDs but could not find the answer to my
question: Medicare will cover a shoe attached to a brace (L3224, L3225)
but will the contralateral shoe be covered and is there a way to bill
for custom shoes attached to the brace?
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Medicare in our experience will only pay for the shoe attached to the
brace (and even that reimbursement is quite minimal). We’ve always had
to charge the pt. for the other shoe, unless they were diabetic. They
don’t have an orthopedic custom shoe code that I’m aware of, only the
A5501 for our diabetic pts. Good luck.
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I will answer part of your question. No, Medicare does not pay for the
non involved shoe. It will have to be paid for by the patient. I just
attended a Medicare seminar and that question got asked. Make sure you
use all the modifiers for the shoe attached to the let Medicare know it
is a covered item. Medicare won’t pay for the custom shoes if it is not
a diabetic patient either which may not be part of your question. If the
shoes are for a diabetic patient they would be covered with or without
the brace, just rivet on the brace being made without any worries and
code it appropriately.
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Hi Jim, my understanding over the years is that Medicare will only cover
the shoe attached to the brace, and only with a new brace order, not a
replacement shoe. They never pay for the opposite side shoe, non-braced
side. If you bill for a custom shoe they will pay for a simple
orthopedic shoe attached to the brace. Custom shoes are only covered for
a diabetic and has nothing to do with the brace. They will pay as a pair
in the case of a diabetic. Good luck.
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You asked on the perfect day. Yesterday Region C had a webinar about ortho
shoes. It is my understanding that the contralateral shoe is NOT covered.
A custom molded shoe can be covered if the patient meets the medical
requirements for the custom molded shoe and that can be attached to a brace.
Attached is the a copy of the presentation from yesterday’s webinar.
(I have attached the webinar file for those interested.)
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My experience has been that only the shoe attached to the brace is
covered. The contralateral shoe is the patient’s responsibility
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it is my opinion, speaking from previous experiences, that answer is
yes. they will, also, pay for any shoe modifications and INSERT for the
shoe that is attached to the brace. you will need to have a nice lmn
compiled and signed by the good doctor, to justify custom shoe though.
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Hi we just had this issue recently ourselves. As far as I know there
are no L-codes for custom shoes attached to a brace. As a matter of
fact we ended up using a special off the shelf shoe from Apis that fit
very well because we could not find a custom shoe code attached to a
brace. Apis does make shoes for extreme edema and charcot foot, which
are OTS. I have been happy with the fit. There is a L-code: L3250,
which is the custom shoe code, however there is usually no fee
associated it. I am not even sure it is a valid code anymore. And my
understanding always has been that Medicare does NOT cover the
contra-lateral shoe and the patient has to. We just bill for say,
L3224x1. If i am wrong about this then someone please correct me.
—
Jim Thelen, LPO
Trinidad Medical Consultants
[email protected]
214-340-6200
