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There may also be differences between plans within an insurer, so it is important to be aware of possible subtle differences. Documentation of codes and policies regarding coverage in the medical record can help to prevent issues regarding billing and payment. The podiatrist should be aware of these details so that they can direct and work with their staff as to the most appropriate billing.
The medical record should clearly document the patient’s podiatric complaint with the history of the complaint, previous treatments rendered, past medical and podiatric history that may be associated with the diagnosis(es) that you are wanting to treat with custom orthotics. I recommend sending a letter of medical necessity to the insurance company along with the associated medical record documentation. The letter of medical necessity should be detailed as to the specifics of the patient’s condition and why they need the type of device you are prescribing. The letter should discuss the specifics of the device including modifications you are using to treat the patient’s condition(s).
The most commonly recognized code for orthotic billing in podiatry is L3000. The AOPA, APMA and PFA have approved specific detailed descriptions regarding L-code clarification for the following codes; L3000, L3010, L3020 and L3030. The document is entitled L-Code Foot Orthotic Clarification and can be found online. This document gives a detailed description of each code to help the podiatrist select the most appropriate code. I recommend becoming familiar with the document. Of course, the podiatrist should use the code appropriate to the patient’s insurance coverage and policies.
The code L3000 is appropriate for a functional device with a heel cup height of 10mm or more. It provides both medial and lateral directive forces to control rear and forefoot motion. Code L3010 is appropriate for an accommodative/ functional device with a heel cup height less than 10mm. It is intended to control the forefoot through a longitudinal arch support. Code L3020 is appropriate for an accommodative/functional device with a heel cup height less than 10mm. It is intended to control the forefoot through a longitudinal arch and metatarsal support. Code L3030 is not typically used in podiatry as the device is formed directly to the patient’s foot by using an external heat source. Most commonly orthotics should be billed as L3000RT and L3000LT along with the proper diagnosis(es) codes.
Examples of billing for devices from ComfortFit Labs are presented. The prescription order form allows the podiatrist to select the heel cup height/depth which can then influence the code selection. Other design factors can also influence code selection.
1. The Leather Shaffer is a low-profile device prescribed for longitudinal arch support. It is usually prescribed with metatarsal support to shift pressure from the metatarsal heads to the metatarsal shafts. If the heel cup height is less than 10mm then L3010(longitudinal arch support) or L3020(longitudinal arch and metatarsal support) could be selected.
2. The Sport Orthotics, Adult Controller, Pediatric Controller are appropriately billed using L3000 as they fit the code description regarding heel cup height and control of rearfoot and forefoot motion.
There are additional codes that can be billed for along with L3000 but again they may not be payable by the insurance company. The unlisted casting code of 29799 includes casting supplies and the actual professional component of obtaining the mold by any means. This code can only be billed once (29799RT, 29799LT). Instead of 29799 one can use code S0395(S0395RT, S0395LT, professional component) along with A4580(cast supplies/plaster) or A4590 (special casting material/fiberglass). I would tend not to use the A4590 code as this is not a typical type of material to be used in casting for Berkeley shell type but for AFO devices.
In summary the doctor and staff should be clear about which codes are payable by an insurance company. Accurate documentation of coverage and the patient’s podiatric history and exam can help create the most accurate billing. ComfortFit Labs aims to help doctors navigate billing concerns. Questions are welcome as we are here to help.
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