Section B - L3000 - L3649 Series Of Codes-013111

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SECTION B: L3000 - L3649 SERIES OF CODESModern Coding for Foot and Ankle DMEPOS HCPCS CodesPage - 21

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CHAPTER BA: OFF THE SHELF SHOES-ADULTOverviewThe PCC differentiates “over the counter” from “off the shelf” as such:· Over the counter (OTC) means “without a prescription”, and could be custom, customized or non-custom workthat is readily dispensed without a prescription. It is rare to do custom work without a prescription, but it canoccur.· Off the shelf (OTS) means “non-custom” and are products that are mass produced without any particular wearerin mind. They may be sold “as is,” customized or modified. They may also be sold to be used in conjunctionwith other products/devices to improve their comfort or function. They do not require a prescription, but manytimes they are prescribed.Some of the codes and terms in this chapter contemplate leather soled, separate heeled “orthopedic shoes” thatwere popular in the 1930’s-1970’s. Most Pedorthic work in the 21st century is done using wedge or unit bottomshoes, generally with a polyurethane or EVA (Ethylene Vinyl Acetate) base and a removable inlay.The term “orthopedic shoes” traditionally referred to the leather-soled, separate heeled shoes that were popular inthe 1930’s-1970’s. These shoes usually had several if not all of the following support and accommodation features:· at least 3, usually 5 or more widths.· whole and half sizes.· a Goodyear Welt construction.· low heel pitch.· long medial reinforced counters.· stiff leather uppers.· deep/oblique toe characters.· extended steel shanks.· extra depth construction.In the 21st century, the moniker “orthopedic shoe” has developed a truly negative connotation. Most of the “orthopedicshoe” prescriptions are being filled today with footwear that would be termed “athletic” or “walking” or “casual.”Modern “Pedorthic” shoes generally have the following support and accommodation features:· American Lasts: generally 3 or greater widths and whole and half sizes.· European Lasts: generally roomy forefoot fits and tight vamp fits, with metric or UK sizing.· Removable inlay to accommodate a foot orthosis.· Wedge bottom. The wedge bottom construction greatly diminishes the need for a shank (unlike a separateheel), but most better-grade shoes have some sort of shank anyway.· Unit bottom, generally of polyurethane and/or EVA.· Low heel pitch.· Reasonably strong counters.· Oblique toe character.· Good medial/lateral stability.· Generally—deeper toe boxes than most shoesPopular “Pedorthic” shoes in the 21st century have included (but by no means limited to) technical grade running andwalking shoes. With the advent of the Therapeutic Shoes for Diabetics Medical Policy, there has been an explosionof offerings by companies for shoes that meet the definition of A5500. These shoes generally share the list offeatures found in “Pedorthic” footwear, with the notable exception of European sizing, which is prevented by law.Modern Coding for Foot and Ankle DMEPOS HCPCS CodesPage - 23

In addition to these American brands, there are a number of European shoes with great Pedorthic integrity. Thoughmost of these shoes lack the combination of sizes and widths that American Pedorthic shoes offer, these shoes arePedorthic mainstays in Europe and have become very important in the United States since the late 1990’s. Despitethe acknowledged benefits of these shoes, the PCC favors the complete exclusion and non-coverage of shoesunless they come in at least three graded widths. This is a public policy position, with the rationale that with all elsebeing equal, beneficiaries will be better fitted in shoes that come in widths, and therefore the HCPCS system shouldendorse and promote such footwear.Width is a measure of circumference of the ball of a shoe. However, in a quality shoe, the manufacturer will, forevery other width, not just add more upper material, but also use a wider midsole/outsole base. This is referred toas a graded-width. A lower cost manufacturing process will attempt to put three different sized uppers (or threeindividually marked shoe sizes) on one sized base. The PCC has clarified that for pedorthic footwear, a maximumof two individual marked shoe sizes may be used per unit bottom so that the sole width is graded to the size andwidth of the upper portions of the shoe. As described above, the PCC favors the American standard last sizingschedule or its equivalent. (The American last sizing schedule is the numerical shoe sizing system used for shoesin the United States.)The PCC favors closed toe “shoes” and “boots” for Pedorthic treatment. Sandals can support, but they cannotprotect the foot. The PCC favors styles that can protect the foot. Slip-on shoes (especially dress shoes) have theweakest control of any shoe. The PCC favors shoes that can support, protect, and control the foot—and this rulesout the vast majority of all sandals, slip-ons, and dress shoes.The variety of shoes available is so vast, it would be almost impossible for a code set to adequately and fairlyaccount for all options. It would overcompensate poor quality shoes and undercompensate high quality shoes—which is exactly opposite of what should happen. This underscores the need for qualified provider language.Qualified providers not only have the training to know which shoes will work, they also have the code of ethics andthe internal policing mechanisms to ensure that the right shoes are dispensed.The PCC applauds the use of different codes for men’s and ladies shoes since almost all footwear companiesdifferentiate the pricing between the two genders, with men’s shoes being more expensive than ladies’ shoes.Most private insurance companies do NOT routinely cover OTS shoes. The PCC actually supports this decisionbased on the following reasons:1) there is such a broad range of shoes available that it would be virtually impossible to pick one allowableamount that would be fair to both insurance company and providers. No other item in the L3000-L3649series has as much diversity. Routine non-coverage allows the market mechanism to allocate prices andencourages innovation by ensuring fair compensation for footwear.2) since everyone wears shoes and everyone is accustomed to buying their own shoes—beneficiariesaccept the notion of non-coverage for shoes—just like their mattresses and toothbrushes. If every beneficiaryhad 100 allowed for shoes per annum, then insurance premiums would increase by at least 100 perannum.3) it frees up health care dollars to be used for more non-standard/specialty items—such as foot orthosesand shoe modifications. It would be wrong to say “more important” items, since shoes have the mostimpact on foot health, and are necessary for the proper functioning of all other codes.Page - 24Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

If a third-party payor were to cover OTS shoe codes, there would need to be at least 20 shoe codes that would needto be created to adequately and fairly handle OTS shoes. The PCC has recommended non-coverage, and so thesmall number of codes can be used to merely track the activity for these items (rather than reimburse them).The main codes currently in existence are:LADIES’ OTS SHOES-NOT ATTACHED TO BRACEL3215 ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACHL3216 ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACHL3217 ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACHMEN’S OTS SHOES-NOT ATTACHED TO BRACEL3219 ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACHL3221 ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACHL3222 ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACHOTS SHOES ATTACHED TO A BRACEL3224 ORTHOPEDIC FOOTWEAR, WOMAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)L3225 ORTHOPEDIC FOOTWEAR, MAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS)OTHER SHOE CHARGESL3254 NON-STANDARD SIZE OR WIDTHL3255 NON-STANDARD SIZE OR LENGTHL3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZESPECIALTY OTS SHOESL3260 SURGICAL BOOT/SHOE, EACHL3265 PLASTAZOTE SANDAL, EACHThese code descriptions are not ME-CE—and have caused much confusion. In addition, there are important codesmissing from this area regarding newer advances, and they should be added.As such, the PCC recommends the following (beginning on page 26):Modern Coding for Foot and Ankle DMEPOS HCPCS CodesPage - 25

Old DescriptionPCC/New DescriptionExplanationLADIES’ OTS SHOES - NOT ATTACHED TO BRACEL3215 Pedorthic OTS Shoe,Ladies’ low top with adjustableclosure, available in at leastthree graded widths, closed toe,separate heeled constructionwith shank, any material bottom,with or without depth inlay, eachfoot.This code is defined as “ladies’ low top withseparate heel”. Generally, these will beleather soled shoes (i.e. the old styleorthopedic shoes), but the code is open forany sole material if it has a separate heel.The shoe must have some sort of closure,be it laces, hook-and-loop, straps, etc. Theshoe must have some sort of shank since itis a separate heel, and must have Pedorthicsupport and accommodation qualitiesabove and beyond “regular” footwear. Aqualified provider will know the difference.L3216 ORTHOPEDIC FOOTL3216 Pedorthic OTS Shoe,WEAR, LADIES SHOE, DEPTH Ladies’ low top with adjustableINLAY, EACHclosure, available in at leastthree graded widths, closed toe,wedge or unit bottom construction, any material bottom, fulllength depth inlay, each foot.This code is defined as “ladies’ low top withwedge or unit bottom”. This definition willcover anything from athletic shoes to shoesthat qualify as A5500. The shoe must havesome sort of closure, be it laces, hook-andloop, straps, etc. The shoe must havePedorthic support and accommodationqualities above and beyond “regular”footwear. A qualified provider will know thedifference.L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOE,HIGHTOP, DEPTH INLAY,EACHThis code is defined as “ladies’ high top withany bottom”. The shoe must have somesort of closure, be it laces, hook-and-loop,straps, etc. The shoe must have Pedorthicsupport and accommodation qualities aboveand beyond “regular” footwear. A qualifiedprovider will know the difference.L3215 ORTHOPEDICFOOTWEAR, LADIES SHOE,OXFORD, EACHPage - 26L3217 Pedorthic OTS Shoe,Ladies’ high top with adjustableclosure, available in at leastthree graded widths, closed toe,any bottom construction, anymaterial bottom, full lengthdepth inlay, each foot.Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

Old DescriptionPCC/New DescriptionExplanationMENS’ OTS SHOES - NOT ATTACHED TO BRACEL3219 ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACHL3219 Pedorthic OTS Shoe,Men’s low top with adjustableclosure, available in at leastthree graded widths, closed toe,separate heeled constructionwith shank, any material bottom,with or without depth inlay, eachfoot.This code is defined as “men’s low top withseparate heel”. Generally, these will beleather soled shoes (i.e. the old styleorthopedic shoes), but the code is open forany sole material if it has a separate heel.The shoe must have some sort of closure,be it laces, hook-and-loop, straps, etc. Theshoe must have some sort of shank since itis a separate heel, and must have Pedorthicsupport and accommodation qualitiesabove and beyond “regular” footwear. Aqualified provider will know the difference.L3221 ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTHINLAY, EACHL3221 Pedorthic OTS Shoe,Men’s low top with adjustableclosure, available in at leastthree graded widths, closed toe,wedge or unit bottom construction, any material bottom, fulllength depth inlay, each foot.This code is defined as “men’s low top withwedge or unit bottom”. This definition willcover anything from athletic shoes to shoesthat qualify as A5500. The shoe must havesome sort of closure, be it laces, hook-andloop, straps, etc. The shoe must havePedorthic support and accommodationqualities above and beyond “regular”footwear. A qualified provider will know thedifference.L3222 ORTHOPEDIC FOOTWEAR, MENS’ SHOE,HIGHTOP, DEPTH INLAY,EACHL3222 Pedorthic OTS Shoe,Men’s high top with adjustableclosure, available in at leastthree graded widths, closed toe,any bottom construction, anymaterial bottom, full length depthinlay, each foot.This code is defined as “men’s high top withany bottom”. The shoe must have somesort of closure, be it laces, hook-and-loop,straps, etc. The shoe must have Pedorthicsupport and accommodation qualities aboveand beyond “regular” footwear. A qualifiedprovider will know the differenceModern Coding for Foot and Ankle DMEPOS HCPCS CodesPage - 27

Old DescriptionPCC/New DescriptionExplanationL3224 ORTHOPEDIC FOOTWEAR, WOMAN’S SHOE,OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)L3224 Pedorthic OTS Shoe,Ladies’ any height with adjustable closure, available in at leastthree graded widths, closed toe,any bottom construction, anymaterial bottom, full length depthinlay, used as an integral part ofan attached brace or AFO, eachfoot.The PCC recognizes that this code shouldbe used for any L3215, L3216, or L3217 thatis permanently attached to an AFO. TheseAFOs are generally double or singleuprights. If the shoe cannot meet thedefinition of L3215, L3216, or L3217, itcannot be an L3224 Medicare does pay forthis code, so practitioners need to stayabreast of Medicare guidelines and, to theextent that they differ from PCC guidelines,the Medicare guidelines control for Medicare. PCC recognizes the third partypayors need to recognize this unique codeto describe a shoe permanently attached toan AFO. These beneficiaries would havehad to buy shoes even if they had notdeveloped the condition necessitating thebrace. See Section D.L3225 ORTHOPEDIC FOOTWEAR, MAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)L3225 Pedorthic OTS Shoe,Men’s any height with adjustableclosure, available in at leastthree graded widths, closed toe,any bottom construction, anymaterial bottom, full length depthinlay, used as an integral part ofan attached brace or AFO, eachfoot.The PCC recognizes that this code shouldbe used for any L3219, L3221, or L3222 thatis attached to an AFO. These are generallydouble or single upright AFOs. If the shoecannot meet the definition of L3219, L3221,or L3222, it cannot be an L3225. Medicaredoes pay for this code, so practitionersneed to stay abreast of Medicare guidelinesand, to the extent that they differ from PCCguidance, the Medicare guidelines controlfor Medicare. PCC recognizes the thirdparty payors need to recognize this uniquecode to describe a shoe permanentlyattached to an AFO. These beneficiarieswould have had to buy shoes even if theyhad not developed the condition necessitating the brace. See Section D.OTS SHOES ATTACHED TO BRACEPage - 28Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

Old DescriptionPCC/New DescriptionExplanationL3254 NON-STANDARD SIZEOR WIDTHL3254 Pedorthic OTS Shoe,unisex, charge for non-standardshoe width and/or length, eachfoot.This code can only be used if the manufacturer of an OTS shoe charges the practitioner an incremental charge relating to a sizeor width that is outside of a normal size run.The charge must be 1) actually paid, and 2)incremental to a standard size. The PCCrecommends blanket non-coverage of thiscode, just like the OTS shoe codes.L3255 NON-STANDARD SIZEOR LENGTHDiscontinueThe PCC believes only one code isneeded—usually non-standard lengths andwidths go hand in hand, and there is usuallyjust one charge paid.OTHER SHOE CHARGESL3257 ORTHOPEDIC FOOTL3257 Pedorthic OTS Shoe,WEAR, ADDITIONAL CHARGE unisex, additional charge forFOR SPLIT SIZEsplit size, each.Modern Coding for Foot and Ankle DMEPOS HCPCS CodesSplit sizes usually happen in one of twoways: 1) the manufacturer of an OTS shoehas a program whereby they will split thesize at the manufacturer level for an additional charge, 2) the manufacturer has nosuch program and the practitioner must selltwo pairs of shoes to the patient. Mostpractitioners will give the patient a discounton the second pair, while requiring thesurrender of the contralateral shoes to 1)prevent abuse, 2) use as samples, and/or 3)donate to charity. This code may be usedto bill the increment charged to the beneficiary that is a) incremental over the price ofa normal pair of shoes, and b) actually paid.The PCC recommends blanket non-coverage of this code, just like the OTS shoecodes.Page - 29

Old DescriptionPCC/New DescriptionExplanationSPECIALTY OTS SHOESL3260 SURGICAL BOOT/SHOE, L3260 Pedorthic OTS Shoe,EACHclosed toe, unisex, low or hightop with surgical closure, anynon-leather material, each foot.This code is for any OTS shoe or boot witha surgical closure, made of any non-leathermaterial—i.e. one where the vamp opens allof the way to the toe of the shoe for easierdonning and doffing. It covers most modern“healing shoes.”L3265 PLASTAZOTE SANDAL, L3265 Pedorthic OTS Shoe,EACHopen toe, unisex, low or hightop with surgical closure, anymaterial, each foot.If the healing shoe has an open toe, it isconsidered a sandal, not a shoe. If it has aclosed toe, it is a shoe. Therefore, thiscode would be more appropriate healingsandals and for “cast boots” which are openin the front and are essentially strap onsoles to go over a walking cast.L3BAA (must currently useL3649) Pedorthic OTS Shoe,closed toe, unisex, low or hightop with surgical closure, leatherupper, each foot.This code is for any OTS shoe or boot with asurgical closure and leather uppers—i.e. onewhere the vamp opens all of the way to thetoe of the shoe for easier donning anddoffing. It covers only the traditional leatherhigh top shoe with lacing to the toes.FAQ:Q: Why does the PCC advocate the routine non-coverage of OTS shoes?A: The PCC actually supports this decision based on the following reasons:1) there is such a broad range of shoes available that it would be virtually impossible to pick one allowableamount that would be fair to both insurance company and providers. No other item in the L3000-L3649series has as much diversity. Routine non-coverage allows the market mechanism to allocate prices andencourages innovation by ensuring fair compensation for footwear.2) since everyone wears shoes and everyone is accustomed to buying their own shoes—beneficiariesaccept the notion of non-coverage for shoes—just like their mattresses and toothbrushes. If every beneficiaryhad 100 allowed for shoes per annum, then insurance premiums would increase by at least 100 perannum.3) it frees up health care dollars to be used for more non-standard/specialty items—such as foot orthosesand shoe modifications. It would be wrong to say “more important” items, since shoes have the mostimpact on foot health, and are necessary for the proper functioning of all other codes.All rule making is a form of “line drawing”. The line has to be drawn somewhere and certainly bright lines can be bothover and under inclusive (include items that should not have been and exclude items that should not have been).Page - 30Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

Q: Why did the PCC exclude slip-on shoes and sandals, when certainly some would qualify as being pedorthicallyviable?A: Though some sandals and some slip-on shoes would be widely regarded as “pedorthically sound”, most of theshoes in these categories would not. Slip-on shoes have a very low ability to control the foot, relative to shoes withadjustable closures, all else being equal. Likewise, slip-on shoes generally need to be fit more snuggly thanshoes with an adjustable closure—thus running the risk of irritating the foot. The PCC would specifically like toexclude typical so-called “dress shoes.”Likewise, sandals cannot generally protect the toes, relative to closed-toe shoes. Protecting the toes is often amajor goal of Pedorthics.Q: What if you dispense a man’s shoe to a woman (to fit large size or width)? Should it be billed with the“men’s” codes or the “woman’s” codes?A: You would use the Men’s shoe codes. Those shoes are more expensive, and the coding allowables should behigher. PCC recognizes the medical necessity of fitting some women on men’s lasts and fitting some men onwomen’s lasts.Q: Would a clog with an adjustable back strap qualify for these codes? How about a clog that has a nonadjustable back or no-back?A: The adjustable back strap would qualify for an “adjustable closure” The other two would not.Q: Why did the PCC recommend a minimum of 3 graded widths when this would automatically exclude anumber of excellent European shoes?A: Remember, the PCC advocates the non-coverage of all OTS shoes, making the point somewhat moot. The PCCrecognizes that many European Pedorthic-grade shoes offer excellent qualities, but do not come in 3 gradedwidths. The PCC recognizes that even though a shoe comes in one width—you can properly fit someone with it,and likewise, even though a shoe comes in three widths—you can misfit someone with it. That is a major reason thatthe PCC recommends qualified provider language to provide some assurance that the practitioner helping thebeneficiary has some knowledge of shoe fit and can determine whether the shoe fits. However, the PCC recognizesthat shoe fitting is a blend of art and science, and involves several shades of gray and lots of judgment. The PCCbelieves that from a public policy standpoint that beneficiaries over time will receive better care if the three gradedwidths rule is included in the definition, especially in cases where the third party payor ignores the PCCrecommendations and provides coverage for OTS shoes.Q: Does Medicare currently have a specific code for Custom Shoes Attached to a Brace?A: No. Currently, Medicare has a defined code for OTS shoes attached to a brace, but does not have a definedcode for Custom Shoes attached to a brace. This creates a complicated billing situation. Until Medicare canharmonize this particular policy, the PCC believes a separate code is required for Custom Shoe attached to abrace. For more information see chapter BI.Modern Coding for Foot and Ankle DMEPOS HCPCS CodesPage - 31

SEPARATE HEELLONG MEDIAL COUNTERGOODYEAR WELT CONSTRUCTIONLEATHER SOLE, MIDSOLE AND UPPERONE INCH HARD RUBBER HEELGREAT FOR THOSE WHO DRAG THEIR FEETOR NEED MAXIMUM SUPPORTTRADITIONAL GIRL SCOUT SHOE USED INDOUBLE UPRIGHT METAL BRACESWEDGE BOTTOMIN DEPTH CONSTRUCTIONWEDGE OR ROCKER SOLE FOR MAXIMUMSHOCK ABSORPTIONREMOVABLE 1/4 INCH INNERSOLEORTHOPEDIC STEEL SHANKS AND EXTENDEDCOUNTERSImages courtesy of Tom Browner, used with permission.Page - 32Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

CHAPTER BB: ROCKER SOLES, ROCKER BARS, METATARSAL BARS, AND MARCH BARSRocker soles, rocker bars, metatarsal bars, and march bars all work to create a fulcrum on the forefoot that affectsgait and/or relieves pressure on the forefoot. Generally we use “rocker soles” when talking about a wedge or unitbottom shoe. We use “metatarsal bars” or “rocker bars” when talking about a separate heel shoe. Rarely are“metatarsal/rocker bars” added to wedge bottom shoes because they can create an uneven walking surface and anegative heel.Generally “rocker bars” are larger than “metatarsal bars” and have the primary purpose of creating a fluid gait overthe forefoot. “Metatarsal bars” are usually smaller and placed with the primary purpose of unloading the forefoot—usually the metatarsal heads. March bars are the most proximal of the metatarsal bars and are used to unload themetatarsal heads. For coding, the codes are based on HOW the device is constructed (forefoot bar or entire sole),not necessarily where the apex of the rocker is, nor the primary purpose of the rocker.The main codes currently in existence are:L3400 METATARSAL BAR WEDGE, ROCKERL3410 METATARSAL BAR WEDGE, BETWEEN SOLEL3595 ORTHOPEDIC SHOE ADDITION, MARCH BAROther important codes:L2360 ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANKThese code descriptions are not ME-CE—and have caused much confusion. To be mutually exclusive—the codeswould either need descriptions based on type (i.e. “Rocker sole” versus “Rocker/Metatarsal Bar”) or constructiontechnique (i.e. “Added outside of sole” versus “added between sole”).The PCC has determined that the most sensible distinction is to distinguish the four possible options, since theirdifferences are in fabrication labor time. The time involved is the main driver between giving these different levelsof reimbursement.As such, the PCC recommends the following:Old DescriptionPCC/New DescriptionExplanationL3400 METATARSAL BARWEDGE, ROCKERL3400 Shoe modification/addition: outsole, rocker bar ormetatarsal bar added to forefootof shoe, attached to bottom ofoutsole, each foot.To be used when a bar is added. This baris added to the outside of the sole. This isgenerally done to separate heel shoes. Forcustom shoes, see Footnote X.L3410 METATARSAL BARWEDGE, BETWEEN SOLEL3410 Shoe modification/addition: outsole, rocker bar ormetatarsal bar added to forefootof shoe, inserted betweenmidsole and outsole, each foot.To be used when a bar is added. This bar isinserted between the outsole and midsole.This is generally done to separate heelshoes. For custom shoes, see Footnote X.Modern Coding for Foot and Ankle DMEPOS HCPCS CodesPage - 33

Old DescriptionL3595 ORTHOPEDIC SHOEADDITION, MARCH BARL2360 ADDITION TO LOWEREXTREMITY, EXTENDEDSTEEL SHANKPage - 34PCC/New DescriptionExplanationL3BBA (must currently useL3649) Shoe modification/addition: outsole, rocker soleadded to wedge bottom shoe,attached to bottom of outsole,each foot.To be used when the rocker sole is attached to the outside of the outsole. This isdone for wedge or unit bottom soles. Forcustom shoes, see Footnote X.L3BBB (must currently useL3649) Shoe modification/addition: outsole, rocker soleadded to wedge bottom shoe,inserted between midsole andoutsole, each foot.To be used when the original outsole is cutoff, and the rocker sole is done betweenthe outsole and midsole, and the outsole isreplaced. This is done for wedge or unitbottom soles. This code requires thereplacement of the outsole, so it will almostalways be billed along with: L3540 full soles(see Chapter BE). For custom shoes, seeFootnote X.DiscontinueMarch bars (L3595) are a form of metatarsalbars (L3400). March bars represent themost proximal of the metatarsal bar—generally in the shank of the shoe. Thegoal of the march bar is to create a distinctoffloading apex within the shank area,proximal to the metatarsal heads to offloadthe metatarsal heads. It is of comparablework to a metatarsal bar. The PCC believesthat there is not a need for the march bardistinction from metatarsal bars.L2360 Shoe modification/addition: outsole, steel shankbent, inserted, and fastenedbetween outsole and midsoleof shoe, each foot.This is a steel plate designed to be insertedbetween the midsole and outsole of theshoe. The purpose of the plate is to stopthe sole of the shoe from bending. It mustbe molded by hand to follow the propercontour of the shoe.L3BBC (must currently useL3649) Shoe modification/addition: outsole, highstrength, lightweight material,all hybrid lamination/prepregcomposites shank bent,inserted, and fastenedbetween outsole and midsoleof shoe, each foot.Like 2360, but when the shank is made fromhigh strength, lightweight material, all hybridlamination/prepreg composites. This couldinclude carbon fiber or fiberglass.Modern Coding for Foot and Ankle DMEPOS HCPCS Codes

Footnote X: These codes are often applied to OTS shoes and can be used when coding-out a new custom shoeif 1) it is an upgrade over the base sole provided, and 2) there is an actual incremental charge paid to the lab for thisitem. These codes can be used to later modify an existing custom shoe. For more information, see the chapter oncustom shoes at chapter BI.All else being equal, a metatarsal/rocker bar is less labor intensive to do than a rocker sole because it is theforefoot only. The former also involves less material because it is forefoot only. The additions attached to theoutside of the sole are less labor intensive than those inserted between the midsole and the outsole. These codesinclude material added up to 1/4 inch. Beyond that, the practitioner should bill for a lift code. Rocker soles codesincludes material added up to one-quarter of an inch. Above that, the practitioner should also bill for additionalelevation (see elevation codes at chapter BC).FAQ:Q: What if a metatarsal bar or rocker bar is added outside of the sole of the shoe, then a protective outsole isadded to protect the bar (i.e. a rubber or firm crepe bar is added, and then an outsole or sole guard material isadded on top of that)?A: The bar would be a L3400. A half sole was then added, so the L3530 half soles would be appropriate (seechapter BE). L3410 would not be appropriate since the original sole was not cut off.Q: I added a rocker sole to unload a forefoot on a men’s size 15 wedge-bottom shoe. In order to get enoughroom to unload the foot, I had to add one-half inch under the affected limb and then a compensating rocker ofone-half inch on the other foot. How would this be coded?A: The first one-quarter inch of material per side is included in the definition of between sole, rocker sole, L3BBB.This would therefore be two units of between sole, rocker sole L3BBB and two units of L3310 since each sideneeded one-quarter inch of L3310. See chapter BC on elevations.Q: I added a metatarsal bar under the ball of a separate heel shoe and need to also elevate the heel to rebalancethe shoe—what heel code would I use?A: Use L3334: if the shoe is a separate heeled shoe, and the heel also needs to be increased. See chapter BC onelevations.Q: If I do a rocker sole that also has other modifications included (i.e. wedges, stabilizers, and elevations) canI bill for all of the work that I have done?A: Yes. Many times a complex shoe modification will simultaneously require wedging, el

2) since everyone wears shoes and everyone is accustomed to buying their own shoes—beneficiaries accept the notion of non-coverage for shoes—just like their mattresses and toothbrushes. If every beneficiary had 100 allowed for shoes per annum, then insu