“So, to be clear you can never use L3000kx for a diabetic with neuropathy and diabetic ulcers even if secondary will pay.”
HCPCS Level II code L3000 is defined as the following: FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, “UCB” TYPE, BERKELEY SHELL, EACH. Orthotics are statutorily not covered by Medicare unless they are attached to and are an integral part of a brace.
With respect to diabetic inserts that are usually dispensed in conjunction with extra depth, therapeutic, diabetic shoes, the appropriate, reimbursable HCPCS Level II codes are the following:
A5512 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF ¼ INCH MATERIAL OF SHORE A 35 DUROMETER (OR HIGHER), PREFABRICATED, EACH
A5513 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT’S FOOT, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF ¼ INCH MATERIAL OF SHORE A 35 DUROMETER ORR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH
A5514 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, MADE FROM DIRECT CARVING WITH CAM TECHNOLOGY FROM A RECTIFIED CAD MODEL CREATED FROM A DIGITALIZED SCAN OF THE PATIENT, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER (OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH
If the provider decides to dispense and fit a pair of “FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, “UCB” TYPE, BERKELEY SHELL, EACH,” to a Medicare recipient, this can certainly be reimbursed, as long as the patient’s secondary insurance reimburses for HCPCS Level II code L3000 despite the fact that the device is statutorily not covered by Medicare. In order to bill for the orthotics, the claim must first be submitted to the DME Regional Carrier, the patient’s primary health insurance carrier.
The claim must be appropriately coded and billed so that the rejected claim can be correctly forwarded to the patient’s secondary health insurance carrier that will pay for the orthotics.
It is incorrect to bill L3000-KX, RT and L3000-KX, LT to the DME Regional Carrier. The KX modifier is defined as the following: DOCUMENTATION ON FILE - Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service. When the KX modifier is appended to a HCPCS Level II code such as L3000, it automatically allows for reimbursement from the DME Regional Carrier. The problem is that there is absolutely no documentation in the medical record that justifies the billing and reimbursement of this service. This is a big problem.
The proper billing scenario is to bill to the DME Regional Carrier in the following fashion:
L3000 – GY, RT
L3000 – GY, LT
The GY modifier is defined as the following: NON-COVERED - Use this Medicare modifier on a service or item code when you want to indicate that the service or item is statutorily non-covered or not a Medicare benefit.
The rejection EOB is obtained from the DME Regional Carrier which is then forwarded to the patient’s secondary health insurance carrier which has been confirmed in advance will pay for the orthotics.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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