The Record - Orthopedic footwear, therapeutic shoes will have quantity, frequency limitations, starting April 2017

Orthopedic footwear, therapeutic shoes will have quantity, frequency limitations, starting April 2017

Beginning with dates of service on or after April 1, 2017, therapeutic shoes and orthopedic footwear will have quantity and frequency limitations.

Keep the following in mind:

A-HCPCS and L-HCPCS codes below require LT or RT modifiers or both.

The KX modifier is required for the A-HCPCS codes below ("Therapeutic shoes for persons with diabetes").

Claims will reject if you don’t bill the modifiers.

If the member requires a shoe or insert because of a diabetes-related condition, submit your claim using the appropriate A-HCPCS code for therapeutic shoes for persons with diabetes.

Therapeutic shoes for persons with diabetes

Procedure code

Quantity and frequency

A5500

2 per year

A5501

2 per year

A5503

2 per year

A5504

2 per year

A5505

2 per year

A5506

2 per year

A5512

6 per year

A5513

6 per year

Orthopedic footwear

Procedure code

Quantity and frequency

Procedure code

Quantity and frequency

Procedure code

Quantity and frequency

L3000

2 per
3 years

L3215

2 per year

L3410

2 per
6 months

L3001

2 per year

L3216

2 per year

L3420

2 per
6 months

L3002

2 per year

L3217

2 per year

L3430

2 per
6 months

L3003

2 per year

L3219

2 per year

L3440

2 per
6 months

L3010

2 per
3 years

L3221

2 per year

L3450

2 per
6 months

L3020

2 per
3 years

L3222

2 per year

L3455

2 per
6 months

L3030

2 per
3 years

L3224

2 per year

L3460

2 per
6 months

L3031

2 per
3 years

L3225

2 per year

L3465

2 per
6 months

L3040

2 per year

L3230

2 per year

L3470

2 per
6 months

L3050

2 per year

L3250

2 per year

L3480

2 per
6 months

L3060

2 per year

L3251

2 per year

L3485

2 per
6 months

L3070

2 per year

L3252

2 per year

L3500

2 per
6 months

L3080

2 per year

L3253

2 per year

L3510

2 per
6 months

L3090

2 per year

L3254

1 per year

L3520

2 per
6 months

L3100

1 per
3 years

L3255

1 per year

L3530

2 per
6 months

L3140

1 per
3 years

L3257

1 per year

L3540

2 per
6 months

L3150

1 per
3 years

L3260

1 per year

L3550

2 per
6 months

L3160

2 per
6 months

L3265

1 per year

L3560

2 per
6 months

L3170

2 per
6 months

L3300

3 per
6 months

L3570

2 per
6 months

L3201

2 per
6 months

L3310

3 per
6 months

L3580

2 per
6 months

L3202

2 per
6 months

L3320

3 per
6 months

L3590

2 per
6 months

L3203

2 per
6 months

L3330

2 per
6 months

L3595

2 per
6 months

L3204

2 per
6 months

L3332

2 per
6 months

L3600

2 per
6 months

L3206

2 per
6 months

L3334

3 per
6 months

L3610

2 per
6 months

L3207

2 per
6 months

L3340

2 per
6 months

L3620

2 per
6 months

L3208

2 per
6 months

L3350

2 per
6 months

L3630

2 per
6 months

L3209

2 per
6 months

L3360

2 per
6 months

L3640

2 per
6 months

L3211

2 per
6 months

L3370

2 per
6 months

L3440

2 per
6 months

L3212

2 per
6 months

L3380

2 per
6 months

L3450

2 per
6 months

L3213

2 per
6 months

L3390

2 per
6 months

L3455

2 per
6 months

L3214

2 per
6 months

L3400

2 per
6 months

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.