A Code Responses

A Code Responses

John T. Brinkmann, CPO, LPO, FAAOP

6/28/2002

Here are the responses to my question regarding the use of A codes when
billing a pair of shoes for a patient with a BK on one side.

Thanks to all who responded.

John Brinkmann, CPO


Well there on;y going to pay for one shoe, the one on the AFO, and I use
the A5500ZX the same code I use for Medicare as they are Diabetic shoes.




The A-codes are only used by Medicare. If the patient's primary
insurance is
other, you should use the Lcode equivalents.
Asumming the BK is male patient on the left side, your shoe codes should
be:
L3040 RT (x1) insert prefab
L3225 RT (x1) shoe for use with a brace

Depending on the patient's plan, if shoes are covered (most plans don't)
add:
L3040 LT (x1)
L3225 LT (x1)

Hope this helps.



  To my knowledge, the Medicare A codes are to be used for Medicare
diabetic clients only. The code I use for private ins.
is L3221 (extra depth shoes).



Don't use the A codes for anyone not diabetic covered by Medicare.
Use a
traditional L code.

I would be fitting Apex Ambulators and would use L3216.

I have a good size stock of these shoes and find it very handy to fit
from
the stock and then order a specific shoe for the patient in their color
and
closure choice.

SPS in Dallas has stocked them for me so I don't have to pay extra
shipping
from outside of Texas.



Sounds to me that this would normally be a noncovered item thru an
insurance company. The prosthetic side is not
medically necessary and on the contralateral side you would need to
document why it would be medically necessary. The best
course of action would be to bill the patient privately or have them
purchase their own shoes.



If the patient has Medicare, according to a letter from the DMERC
medical
directors the shoes are both covered even though the patient has a
prosthesis on one side. You would use A codes.

If the insurance company you are working with follows Medicare's
guidelines - you may want to ask them - they should do the same. Your
contract, if you have one, may say so.

I would use the A codes, if the insurance company accepts them, it is
cleaner. That is the way you would do it with Medicare so a precedent
has
been set. If they do not accept A codes, I would consider L3224 or L3225
if
the brace is metal on the one side. Your problem is on the other side.
If
the brace is plastic I would consider the L3215-21 codes, depending on
the
type of shoes. These codes represent pairs and would handle the
situation
well.

Hope this helps.



I believe if the patient does not have M-care, the A codes should not be
used. You should use the L-codes for Xdepth ortho shoes as you would if
you
would patient was not diabetic.