CODING, COVERAGE AND REIMBURSEMENT

This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well.

General

• Overall, . These items are only covered if used at the beneficiary's residence (place of service 12) and are not separately payable if items are supplied at physician's office or hospital outpatient department.
• Medicare coverage of therapeutic shoes is managed by Medicare  Medicare Administrative Contractors (MAC). Coverage is explained by the:
• Local Coverage Determination (LCD): Therapeutic Shoes for Persons with Diabetes (L33369) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33369&ContrID=140
• Local Coverage Article: Therapeutic Shoes for Persons with Diabetes - Policy Article (A52501) https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52501&ContrID=140
• The following items are covered by Medicare Part B when requirements are met:

Therapeutic shoes

• HCPCS of covered items:
•  custom molded shoes (A5501) (which includes inserts provided with these shoes),
• inserts (A5512 or A5513); or 
• depth shoes (A5500)
• modification of a custom molded or depth shoes :  rigid rocker bottoms (A5503), roller bottoms (A5503), wedges (A5504), metatarsal bars (A5505), or offset heels (A5506). Other modifications to diabetic shoes (A5507) include, but are not limited to flared heels. 
• Coverage requirements:
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• Frequency of replacement allowed by Medicare:
• custom molded shoes (A5501) (includes inserts provided with these shoes): 1 pair per year (calendar year, January-December)
• pairs of inserts (A5512 or A5513): 2-3 extra pairs per year depending on shoes (calendar year, January-December
• depth shoes (A5500)  (includes the non-customized removable inserts provided with such shoes).: 1 pair per year (calendar year, January-December)
• modifications of custom molded or depth shoe (rigid rocker bottoms (A5503), roller bottoms (A5503), wedges (A5504), metatarsal bars (A5505), or offset heels (A5506). Other modifications to diabetic shoes (A5507) include, but are not limited to flared heels):  1 pair per year (calendar year, January-December). 
• Non-covered conditions:
• talk about L3219 and L3260 - non covered?
• Situations other than as a dressing for a qualified wound (VLU that has been debrided)
• Billing reminders:
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• Billable unit: each shoe or insert
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HCPCS Modifiers