Orthopedic Coding Alert

You Be the Coder: Will Medicare Pay for Post-Op Shoe?


- Published on Thu, Jan 01, 2004

Question: Our insurer suddenly stopped reimbursing us for the post-op shoe (L3260). Does this require a modifier or special add-on code to recoup payment?

Tennessee Subscriber

Answer: Medicare considers L3260 (Surgical boot/shoe, each) a noncovered code because this service is statutorily excluded from Medicare benefits. Several private payers, such as Aetna and some Blue Cross/Blue Shield insurers, do cover the surgical boot for postoperative conditions.
 
If your insurer doesn't cover surgical boots, you should ask the patient to pay you directly for the item when you dispense it. If the insurer considers the shoe "noncovered," no modifier or add-on code will help you recoup your expense.
 
Medicare doesn't cover surgical boots under any circumstances, so the patient doesn't have to sign an advance beneficiary notice (ABN) in order for you to collect payment. You may, however, ask the patient to sign an ABN to verify that he is aware of his responsibility to pay you for the item.
 
Some patients might ask you to submit a claim for the surgical boot to Medicare so they can request coverage from a secondary insurer. If this occurs with one of your Medicare patients, you should append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to L3260 before submitting the claim to indicate to Medicare that you are aware that you are requesting payment for a statutorily excluded service.

Orthopedic Coding Alert
Issue - Jan, 2004
Already a subscriber? LOGIN to read the article.