Saturday, December 3, 2022

RESPONSES for Shoes Attached to Braces

Karen Schebesta, Office Manager

Good Morning!

Thanks again to everyone for all the responses. =20
They have been a big help! =20
Per your requests, I have cut and pasted all the responses below. =20
Have a happy day!
Karen Schebesta
Karen A. Schebesta, CPC
Office Manager
Orthotic and Prosthetic Center
226 Cedar Wood Plaza, Route 37 West
Toms River, NJ 08755
Tel. 732-341-9191
Fax 732-341-9222
[email protected]

I’m sure you will hear this from others, but Medicare will only pay for the
shoe attached to the brace and the patient is responsible for the other shoe
((I guess they figure that whether the patient wears a brace or not he will
require a shoe on that side anyway so why should they have to pay for it).
Unless, of course, the patient is diabetic and meets shoe qualifications for
Medicare — then you would use A5500 for the opposite shoe.

*****************************************************

I just checked with my office manager and she bills the same way but the=20
shoe NOT attached has no code anymore.=A0 We stopped billing for the=20
non-attached shoe this year.=A0 They haven’t paid for a pair in quite a whil=
e.=20
Guess that second shoe was really strapping Medicare. We do get paid for=20
the attached shoe though.

*****************************************************

Medicare will only pay for the shoe that becomes part of the brace. It will=20
not pay for the other shoe. We have the patient pay for the other shoe.

*****************************************************
It is very simple but,extremely aggravating.You can only get paid on the one=
=20
shoe and discard or give the other shoe away.I would suggestreducing your=20
overhead to make allowance for the extra shoes.
=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=A0=
=A0=A0=A0=A0=A0=A0
*****************************************************

Medicare’s rules are set up this way b/c of the diabetic theraputic shoe
bill. If the patient is not a diabetic then MDE will pay for the shoe
attached to the brace and the other would be noncovered. L3215 is for a pair
of shoes so essentially you are billing MDE for 3 shoes as opposed to 2 (one
pr)

You will need to collect for the patient on the noncovered shoe and if they
wish you to bill MDE anyway then you bill as follows

L322KXLT=A0 for the shoes attached the brace (left)
L3224GYRT which tells MDE this is a noncovered item b/c it is part of the
pair but not covered b/c not attached to a brace

Silly but true

*****************************************************

Karen, under medicare rules they will only pay for a shoe attached to the=20
brace, not the opposite shoe. Bill the patient for the opposite shoe. I bele=
ive=20
they only pay for the initial shoe, not any future shoes attached to the bra=
ce.=20
They may pay labor for a shoe transfer for future shoes , but not the shoe=20
itself. Good luck

*****************************************************

Believe it or not, Medicare considers the orthopedic shoe for the sound
side as “not medically necessary” and will only pay for the shoe
physically attached to the conventional orthosis.=A0 Conversely, with
diabetic amputees in mind, Medicare will not pay for the shoe that is on
the prosthesis, only for the sound side, with CMN documentation. And, if
they are bilateral, neither shoe is covered.

*****************************************************
Unfortunately that is the answer. medicare will only pay for the shoe that i=
s=20
attached to the brace, because it is an intergal part of the brace. you cant=
=20
make a metal afo without a shoe. I guess that that they figure that at least=
=20
they pay for one shoe.

I tell the patients that insurance will only cover the attached shoe and tha=
t=20
they are responsible for the other shoe. I agree that it is absurd, but=20
that’s the way it is. I also offer the option of the patient providing me wi=
th a=20
shoe–which makes them responsible for the fit–but few take me up on it.

*****************************************************
Hate to admit this, but we have been in touch with Medicare and they
specifically say that only the shoe attached to the brace is covered.
Although I agree that this sucks, we are stuck with it.=A0 Normally when I a=
m
in an evaluation with a patient, and they start asking about costs and what
is and is not covered, I address this with them.=A0 I simply make a joke out
of it. Usually, they see the ridiculous humor and understand that they will
have to pay for one shoe.=A0 If I have a patient who truly cannot afford it,=
I
feel that I make enough on the brace itself and break-even on the shoe and
just give the second shoe to the patient at no charge.=A0 I do know some
practitioners who bill twice the price for the one shoe and have gotten
reimbursed, bit I don’t know how that would stand up in an audit situation.

*****************************************************
generally…I have absorbed the cost of the other
shoe….depending on the cost of the shoes…Apex Acor
type…..for p.w.minor type shoes….i give the
patient the truth up front and tell them that if they
want that shoe…they will have to pay the difference=20

*****************************************************
Yep, only the shoe attached to the brace is covered by Medicare- crazy,
stupid, but true.=A0 We charge the patient for the opposite shoe.=A0 Don’t
forget to obtain your ABN for this non covered item!=A0 And the patients
don’t understand this, either.=A0 They get angry with US.=A0 We charge $65
for the opposite shoe.=A0 Well, they can buy a pair off the shelf (at
payless!) cheaper than that!=A0 It’s been such a hassle that we now ask
patients to provide their own shoes.=A0 And we don’t accept the Payless
Shoe Center varieties!=A0 :-)=A0=20

RECENT NEWS

Get unlimited access!

Join EDGE ADVANTAGE and unlock The O&P EDGE's vast library of archived content.

O&P JOBS

Welcome Back!

Login to your account below

Retrieve your password

Please enter your username or email address to reset your password.

The O&P EDGE Magazine
Are you sure want to unlock this post?
Unlock left : 0
Are you sure want to cancel subscription?