Hi list,
I’m posting the replies to the question that I posed about Medicare coverage.
Here is the original question:
>Hi List,
>I have a non-diabetic patient that has a very bad case of RA/OA & has peripheral >neuropathy bilaterally. She also has both of her great toes amputated. Her foot >deformity appears to be simular to the Japanese women that had their feet wrapped. >She has Medicare only and needs shoes & inserts. Is there anything that can be done >utilizing Medicare with her condition? If so, what would be the modifiers?
>I appreciate the responses and will post replies with or w/o names at your option.
>Thanks,
>M. Britt Spears CPO
Here are the responses.(Some preferred to have their names omitted others were not included.)
no codes available…try Mastercard…also call ACOR and maybe they will help with costs if you have used them before….Wesley Marlor, Jr.
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No, there is nothing Medicare will do. You must be diabetic to qualify.
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hey,
try a toe filler insert …L 5000 or 5001…have had luck with that code in the past. H. Jones c.o.
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Medicare will not pay for the shoes, but they will pay for the toe filler. Use that plus the ABN ( for the shoes ) to determine an acceptable amount for reimbursement. Send then as seperate calims. This is the only way to educate medicare on RA so that one day it is a covered item.
Jerry
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Medicare will only pay if the patient is diabetic or the shoe and insert becomes part of a Double Upright brace.
Ed Hicks
UVa P&O Dept
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It has been my experience that there is NO option of billing Medicare for Shoes and Insert without a Diabetic diagnosis, ICD-9 code. Medicare makes no exceptions on these devices that I am aware of.
Sorry!
Kathy Brown
OPRS
Billing and Collection Services
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Please excuse earlier responce. Amputation should be acceptable for some reimbursement.
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Since Medicare only covers footwear for diabetics, these items would not be covered. Some of the costs may be defrayed should she need amputation fillers for inserts (L5000 with RT or LT modifiers). Medicare does not consider RA/OA to warrant foot orthoses and they will be denied as not
medically necessary. There has been talk about seeking coverage for
arthritics, however, the cost factor will most probably preclude inclusion into the therapeutic shoe program, although there would be great benefits to them doing so. A major issue is that arthritics need stabilization of the joints, something that can’t be done very well with inserts. Total contact foot orthoses, properly posted with shoe modifications if necessary, is of great benefit to arthritics. Stabilize the joint and alleviate the pain.
Dean Mason, C. Ped, L. Ped. BOCO, LO
North Shore Pedorthics, Lorain, OH
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If she has both great toes amputated, you could, legally, provide bilateral L5000 insert with toe fillers and throw in the shoes at no cost. You will not get Medicare to pay for the shoes, so have the pt sign the form if you plan to charge them. Since your reimb will be fine for two L5000, it gives you the option to do the shoes.
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Hi Britt, it is my understanding that this patient must be Diabetic for Medicare to purchase her shoes. Ron Cahill CPO
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I am afraid your woman will have to purchase her shoes as Medicare will only pay for shoes if she has diabetes (or, a physician says she does…).
You
could make her partial foot prostheses with toe filler, which would be covered.
Good Luck!
Wendy Beattie, CPO
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Medicare will not pay for shoes or inserts for your client unless you use partial foot amputation as a diagnosis and fab insert with toe filler and use a prosthetic code. I would not risk it but you may.
Steve Mersch CPO
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They are Not covered
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You can use the prosthetic shoe code bilaterally along with L5000 partial foot inserts bilaterally. From the Region C Supplier Manual:
“Prosthetic
shoes (L3250) are covered if they are an integral part of a prosthesis for patients with a partial foot amputation (ICD-9 diagnosis codes 755.31, 755.38, 755.39, 895.0-896.3). Claims for prosthetic shoes for other
ICD-9
diagnosis codes will be denied as not medically necessary.”
Jim Price, PhD, CPO
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L5000 for arch supports
Shoes are out of pocket
Win
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Sorry I wish I had an L code to bill. That’s a tough one. By the way, it was Chinese and not Japanese women of the old days that bound their feet.
J. Tyra Rikimaru, CPO
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OA or RA or any non diabetic will not be paid for by medicare.You have a better chance of buliding braces and using the shoe attached to brace code to get the shoes paid for or else send the bill to the patient.The way I look it is that if she wants to get comfort and support bad enough,a way will be found to pay for them.Look at O&P we do it everyday.Good luck.
Brian Moore CO
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To my knowledge, Medicare will not pay for shoes, unless the patient is diabetic or the shoe is attached to an orthosis. I would suggest that you consider if there is any symptom or condition which would indicate the need for an AFO. In my experience, many RA patients present with ankle pain which could be treated with a fixed or limited motion double bar AFO, or present with a varus or valgus deformity at the ankle which could be treated with a single upright AFO and an appropriate T-strap. If this is the case, the AFO could be deigned to include a split stirrup, so not only could your client have the option in the future for additional shoes, but also the option of removing the orthosis from the shoe. It is my understanding that, if coded properly and with the appropriate documentation for justification, Medicare will pay for shoe modifications to a shoe attached to an orthosis if they are
medically necessary for the function of the orthosis. I wish you well and
look forward to reviewing the other replies.
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Using the Foot Amputation with a KX modifier may get your claim paid.
You can always call Medicare (local region) prior to service and ask for advise too.
Good luck.
Elizabeth Carlstrom
O&P Business Solutions
110 North IH35, Suite 315/217
Round Rock, Texas 78681
512.244.6288 Office
512.244.6299 Fax
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Thank you to all for the replies. Without doubt, we should as a organization try to get Medicare to recognize that grossly deformed arthritic feet are a problem that should receive some recognition.
Thanks again,
M. Britt Spears CPO
Spears Prosthetics and Orthotics
2000 Hwy 25B N. Suite C-1
Heber Springs, AR. 72543
(501) 206-3500
www.Prosthetics-Orthotics.net
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