Blue Cross changing practitioner fees July 1

Blue Cross Blue Shield of Michigan will change practitioner fees with dates of service on or after July 1, 2019. This change applies to services provided to our Traditional, TRUST and Blue Preferred Plus^SM members, regardless of customer group.

Blue Cross will use the 2019 Medicare resource-based relative value scale for most relative value unit-priced procedures for dates of service on and after July 1. Most fees are currently priced using the 2018 values. Keep in mind that the Physician Group Incentive Program allocation of professional fees will remain unchanged this year. The entire adjustment of 1.5 percent will be directed toward increasing the funding of value-based reimbursement, or VBR.

Also, the conversion factor used to calculate anesthesia base units for anesthesia procedures will increase by 1.5 percent.

Fee schedules that are effective July 1 will be available on web-DENIS on April 1. To find fee schedule information, go to the homepage of web-DENIS and follow these steps:

1. Click on BCBSM Provider Publications and Resources.
2. Click on Entire Fee Schedules and Fee Changes, which will bring up the End User Agreement.
3. Click on Accept.

Only claims submitted with dates of service on or after July 1 will be reimbursed at the new rates.

Medicare Plus Blue^SM PPO claim reimbursements

Effective July 1, 2019, Medicare Plus Blue^SM PPO will implement new reimbursement policies for the following claims billed with Healthcare Common Procedure Coding System or Current Procedural Terminology codes that don’t have an assigned Medicare fee.

General reimbursements (for non-durable medical equipment and non-laboratory claims)

• Medicare Plus Blue PPO will reimburse providers 65 percent of the charged amount for all non-DME and non-lab claims that don’t have an assigned Medicare fee.
• For drug claims, pharmacy pricing resources, if available, will be used before reimbursing at 65 percent of charges. For unlisted surgery codes, reimbursement will be made at the rate of a comparable surgery code.

  Note: This payment policy doesn’t apply to procedure codes that currently require an invoice for payment by the Centers for Medicare & Medicaid Services. Also, any CPT codes that are carrier priced will continue to be paid accordingly.

Durable medical equipment

• Medicare Plus Blue PPO will reimburse providers 65 percent of the manufacturer’s suggested retail price for all DME claims that don’t have an assigned Medicare fee.
• Providers must place the manufacturer’s suggested retail price, or MSRP, in the notes section of the claim. If available, DME contracted fees will be utilized before reimbursing at 65 percent of the MSRP.

  Note: This payment policy doesn’t apply to procedure codes that require an invoice for payment either by Medicare Plus Blue or CMS (such as prosthetics, custom-made items, not otherwise specified codes, miscellaneous codes, A4649, A6549 and V2785). Also, any carrier priced CPT codes will continue to be paid accordingly.

Labs (a reminder of the policy that went into effect July 26, 2016)

• Medicare Plus Blue PPO will reimburse providers 65 percent of the charged amount for all lab claims that don’t have an assigned Medicare fee.
• If available, the established lab facility-contracted rate or fee will be used. If there’s no established contracted rate or fee, Blue Cross Blue Shield of Michigan’s commercial rate will be used before reimbursing at 65 percent of charges.

  Note: Supporting documentation for applicable claims is required to determine medical appropriateness and ensure timely processing. Claims will be denied if documentation isn’t attached.

Battling the opioid epidemic: A roundup of news and information

Provider directories identify physicians offering medication-assisted treatment
Physicians specializing in addiction medicine and other practitioners who participate with Blue Cross Blue Shield of Michigan or Blue Care Network and treat members struggling with substance use disorders are identified in our Find a Doctor search feature on bcbsm.com. From the homepage of Find a Doctor, in the Search for doctors, hospitals and clinics by name or specialty field, members can enter Suboxone Treatment for Opiate Addiction to locate providers who are eligible to prescribe medication containing buprenorphine.

Drug Take Back Day scheduled for April 27
The next National Prescription Drug Take Back Day is scheduled for April 27 from 10 a.m. to 2 p.m. For details, see the article in this month’s issue.

Foundation grant helps pregnant mothers fight addiction
The Blue Cross Blue Shield of Michigan Foundation provided grant funding support for a program that helps expectant mothers who are battling substance use disorder. The GREAT MOMS program, which stands for Grand Rapids Encompassing Addiction Treatment with Maternal Obstetric Management, offers support to pregnant women by helping them navigate their prenatal appointments and get medication to treat substance use disorder. The program is currently only available in the West Michigan area, but we’re looking at expanding it to other locations in the future. For more details about the current program, see the MI Blues Perspectives blog.

Next Drug Take Back Day scheduled for April 27

Let your patients know that the next National Prescription Drug Take Back Day is scheduled for April 27 from 10 a.m. to 2 p.m. These twice-yearly events, coordinated by the U.S. Drug Enforcement Administration, are a key tool in our efforts to battle the opioid epidemic.

They provide a safe, convenient and responsible means of disposing of prescription drugs, while also educating the public about the potential for abuse of medications. At the most recent Drug Take Back Day on Oct. 27, 2018, 914,236 pounds of drugs were collected nationwide.

As we’ve done previously, Blue Cross Blue Shield of Michigan will support Drug Take Back Day in various ways. For example, we’ll:

• Post blogs on MI Blues Perspectives.
• Promote resources on our Opioids 101 site.
• Host a Twitter chat during the week of April 22.

To find a drug disposal facility near you that’s participating in Drug Take Back Day, check out the DEA’s search tool** on April 1 or see Michigan OPEN’s Opioid Disposal Map.**

Keep in mind that people who miss the April 27 Take Back event don’t need to wait until the next event in October to safely dispose of unused drugs. For tips on how to safely dispose of unused drugs year-round, see the May 2018 Record article.

Also, Meijer recently launched its new Consumer Drug Take-Back Program** in all Midwest stores. And you can dispose of unused prescription drugs at select Walgreens locations across the state. Read more about Blue Cross’ partnership with Walgreens by clicking here.

For more information on disposing of prescription drugs, visit the DEA Diversion Control Division website** or Michigan OPEN’s Opioid Disposal Information and Resources page.**

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

HCPCS, CPT updates

2019 annual HCPCS maintenance
Procedures/professional services

2019 second-quarter Category III and vaccine updates

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Note: The Federal Employee Program^® follows its own criteria related to procedure codes J3490, J3590, J9271 and J9305.

Enhancements to PPO outpatient claim editing process coming in April

In the September 2018 Record and the December 2018 Record, we told you how we’re updating our claim editing processes for select groups starting in December 2018. We also informed you that the outpatient facility implementation would occur in second-quarter 2019.

The outpatient facility claim enhancements will occur on April 5, 2019. Unique clinical editing reason codes will appear on the 835 response files or provider vouchers.

We hope these enhancements will make our claims payment system easier for you and your billing staff to navigate.

If you have questions about the Blue Cross Blue Shield of Michigan claim editing process, contact Provider Inquiry – Professional at 1-800-344-8525 or Provider Inquiry – Facility at 1-800-249-5103.

What to do when error messages display in e-referral

If you’re a provider trying to edit one of your cases in the e‑referral system, you may see an error message that reads:

The case is unavailable because it’s being reviewed. Please try again later.

Recently, e‑referral began displaying these messages when a provider tried to edit a case that’s locked because our Utilization Management team is working on it.

This error message can appear for any Blue Cross Blue Shield of Michigan or Blue Care Network case in the e‑referral system, including commercial and Medicare Advantage cases. If you encounter one of these messages, we ask that you edit the case later to give our team time to review and exit the case.

If you encounter another type of other error message, contact the Web Support Help Desk at 1‑877‑258‑3932.

Know the inpatient admission appeals process for Medicare Plus Blue Utilization Management department

All Michigan health care providers have the right to appeal an adverse medical decision made by Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM Utilization Management department.

How to request an expedited appeal

You may request an expedited appeal when a decision needs to be made quickly because a delay may seriously jeopardize the life or health of the member. We won’t consider retrospective requests for expedited status. This decision is final; no other appeal option is available.

Request an expedited appeal by calling 1-866-807-4811. Medicare Plus Blue will notify you of our decision within 72 hours.

How to submit first- and second-level appeal requests

You may submit appeal requests by fax, email or mail:

• Fax: 1-877-495-3755
• Email: MedicarePlusBlueInpatientAppeals@bcbsm.com
• Mail:
  Medicare Plus Blue Inpatient Provider Appeal — Mail Code 1516
  Blue Cross Blue Shield of Michigan
  600 E. Lafayette Blvd.
  Detroit, MI 48226-2927

Time frames
A first-level appeal must be submitted within 45 days of the date of the denial decision. Include additional clarifying clinical information to support the request.

Medicare Plus Blue will notify the provider of our decision within 30 calendar days of receiving all necessary information.

A second-level appeal must be submitted within 21 days from the date of the first-level appeal decision. It must contain at least one of the following:

• New or clarifying information
• A clear statement of what the provider is requesting

If neither is included, Medicare Plus Blue isn’t obligated to review the second-level appeal request. We’ll notify the provider of the decision within 45 calendar days of receiving all necessary information. The plan’s second-level appeal decision is final.

Appeals outside the stated time frames
If you request appeals outside the time frames stated above, we’ll deny the first level of appeal request with a decision of untimely filing. We’ll then process the appeal request as a second level. The decision will be final.

At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or external review board.

Note: If an appeal request is received by Blue Cross outside the designated time frame, we’re not obligated to review the case.

Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and Trading Partner IDs don’t change.

Keep these items in mind when changes occur. You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

We’re making updates to Medicare Advantage Physician Office Laboratory List

The Medicare Advantage Office Physician Laboratory List, or POLL, is being updated to reflect changes in CPT coding. The procedures on the list are those that we believe are appropriate to be provided in an office setting. If you provide lab services that aren’t on this list, you won’t be paid. Also, you may not bill the member for a lab service that’s not on this list.

There are 69 codes payable from a provider’s office that are being added to the MA POLL. These include two codes (*80306 and *80307) that were effective for claims submitted with dates of service on or after Jan. 1, 2017. The remainder of the newly added codes will be effective for claims submitted with dates of service on or after April 1, 2019. To view the updated list, click here.

Keep in mind that certain lab procedures may be performed in your office without referring the patient or the specimen to a Medicare Advantage PPO lab network provider if specific conditions are met. They may be performed in your office if:

• The results are needed at the time of service to support making real-time therapeutic decisions.
• The services can be performed economically and accurately.
• The services are medically necessary.

Prior approval needed for FEP non-emergency air ambulance transportation

As of Jan. 1, 2019, Federal Employee Program^® Service Benefit Plan members must receive prior approval for non-emergency air ambulance transportation.

For non-emergency requests
We must review the service for medical necessity before we can apply the benefit. Your clinical information to support a request should answer:

• Why the member needs to be transferred to another facility
• Why he or she wants to use this form of transportation
• Why the destination hospital was chosen

If the request is urgent, a response will be provided within 24 hours. After review, we’ll either approve or deny the request.

For emergency requests
Air ambulance transport for immediate care of a medical emergency or accidental injury doesn’t require prior approval for FEP members.

How to submit prior authorization requests
For prior authorization, call Alacura, an independent company that manages medical transportation requests for Blue Cross Blue Shield of Michigan, at 1-844-608-3676 or fax the pertinent documentation to 1-844-608-3572. If you fax Alacura, indicate on your cover sheet that this is a prior authorization request.

Coding corner: Congestive heart failure

More than a million people in the United States have congestive heart failure. It’s the most common diagnosis in hospitalized patients over the age of 65. One in 9 deaths has heart failure as a contributing cause.

Once CHF is diagnosed, it’s considered a chronic condition and should be evaluated and documented on a yearly basis. When patients with CHF are treated appropriately, however, they may experience minimal or no symptoms. In rare circumstances where it’s due to reversible causes, such as infection, arrhythmia or thyrotoxicosis, CHF may resolve after the underlying cause is treated.

Heart failure is often documented as compensated, decompensated or acute exacerbation. These terms can be confusing to coders, so please refer to these definitions for clarification:

• Compensated CHF indicates that because of ongoing treatment, the patient’s symptoms are controlled and they have no overt features of CHF, such as shortness of breath, lower extremity edema, fluid retention or pulmonary edema. They still, however, carry the diagnosis of CHF.
• Decompensated CHF or acute exacerbation of CHF indicates an acute flare-up of CHF symptoms. This requires intensification of treatment, often in an inpatient setting. When heart failure is documented as decompensated or exacerbated, it should be coded as acute.

Documentation tips

Document congestive heart failure to the highest level of specificity, using all applicable descriptors. The descriptors include:

• Acuity — acute, chronic or acute on chronic
• Type —
  • Systolic — heart failure with reduced ejection fraction HFrEF
  • Diastolic — heart failure with preserved ejection fraction HFpEF
  • Combined systolic and diastolic
• Cause — if known, using terms that clearly show cause and effect, such as associated with, due to, secondary to, or hypertensive.
• Status — stable, worsening, improved, compensated, exacerbated, decompensated.
• Don’t use history of to describe CHF in patients who are asymptomatic. As explained above, except in rare circumstances, CHF is a lifelong diagnosis, while history of implies that the condition has resolved.

Documentation of congestive heart failure should also include:

Clinical signs and symptoms

• Lower extremity edema
• Shortness of breath
• Fatigue

Diagnostic findings

• Echocardiogram showing abnormal ventricular function
• Elevated B-type natriuretic peptide, or BNP
• Chest X-ray or CT scan showing pulmonary vascular congestion or pulmonary edema

Treatment

• Lifestyle modification such as low salt diet, fluid restriction or weight loss as indicated
• Medications such as diuretics, beta blockers, ACE inhibitors or ARBs

Coding tips

Heart failure classifies to ICD-10 code category I50.XX. The fourth character specifies the type of heart failure, and the fifth character specifies the acuity of heart failure.

Examples of heart failure coding are shown in the chart below:

Sources:

• webmd.com**
• 2018 ICD-10-CM Professional for Physicians

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

CDC flyer provides prevention and treatment recommendations for acute bronchitis

Most cases of acute bronchitis clear up on their own without antibiotics — and using antibiotics when they aren’t needed can do more harm than good. Unintended consequences of antibiotics include such side effects as rash and diarrhea, as well as more serious consequences, such as an increased risk for an antibiotic-resistant infection or clostridium difficile infection, a sometimes deadly diarrhea.

The Centers for Disease Control and Prevention has put together a flyer you can give your patients to educate them about acute bronchitis. Topics covered in the flyer include:

• Symptoms of acute bronchitis
• Causes
• When to seek medical care
• Recommended treatment
• Prevention

View the CDC flyer** for more details treating and preventing acute bronchitis.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Transitions to post-acute care facilities for Medicare Advantage patients to be managed by naviHealth starting in June

Authorizations for Blue Cross Medicare Plus Blue^SM PPO and BCN Advantage^SM members who require a transfer from acute inpatient hospitals to skilled nursing, long-term acute care or inpatient rehabilitation facilities will be managed by naviHealth, effective June 1, 2019. naviHealth, an independent company that handles care transitions, will be reviewing both in- and out-of-state post-acute care cases.

Blue Cross and BCN are transitioning to naviHealth as part of an effort to standardize the handling of authorizations for post-acute care for Medicare Advantage members. The change is also expected to provide a more coordinated, patient-focused approach that’s aimed at improving the patient’s physical function and reducing the likelihood of readmission to an acute care setting.

Join us to learn more
Training sessions have been scheduled and will include information regarding the naviHealth clinical model and provider portal. Administrators, case managers, rehabilitation directors, nursing directors are others involved in post-acute patient care are encouraged to attend a webinar. Even if you’re already familiar with naviHealth, we hope you’ll attend to learn how naviHealth will work with Blue Cross Medicare Plus Blue PPO and BCN Advantage patients.

Click on the date and time below to register for your preferred webinar:

Hold the date
Skilled nursing facilities will also be invited to attend in-person forums the week of May 13 in Grand Rapids, Saginaw, Southfield and Traverse City. Registration information will be available in the May issue of The Record.

We’ll bring you additional information about this change in future issues of The Record and BCN Provider News.

Enhancements to PPO outpatient claim editing process coming in April

In the September 2018 Record and the December 2018 Record, we told you how we’re updating our claim editing processes for select groups starting in December 2018. We also informed you that the outpatient facility implementation would occur in second-quarter 2019.

The outpatient facility claim enhancements will occur on April 5, 2019. Unique clinical editing reason codes will appear on the 835 response files or provider vouchers.

We hope these enhancements will make our claims payment system easier for you and your billing staff to navigate.

If you have questions about the Blue Cross Blue Shield of Michigan claim editing process, contact Provider Inquiry – Professional at 1-800-344-8525 or Provider Inquiry – Facility at 1-800-249-5103.

What to do when error messages display in e-referral

If you’re a provider trying to edit one of your cases in the e‑referral system, you may see an error message that reads:

The case is unavailable because it’s being reviewed. Please try again later.

Recently, e‑referral began displaying these messages when a provider tried to edit a case that’s locked because our Utilization Management team is working on it.

This error message can appear for any Blue Cross Blue Shield of Michigan or Blue Care Network case in the e‑referral system, including commercial and Medicare Advantage cases. If you encounter one of these messages, we ask that you edit the case later to give our team time to review and exit the case.

If you encounter another type of other error message, contact the Web Support Help Desk at 1‑877‑258‑3932.

Know the inpatient admission appeals process for Medicare Plus Blue Utilization Management department

All Michigan health care providers have the right to appeal an adverse medical decision made by Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM Utilization Management department.

How to request an expedited appeal

You may request an expedited appeal when a decision needs to be made quickly because a delay may seriously jeopardize the life or health of the member. We won’t consider retrospective requests for expedited status. This decision is final; no other appeal option is available.

Request an expedited appeal by calling 1-866-807-4811. Medicare Plus Blue will notify you of our decision within 72 hours.

How to submit first- and second-level appeal requests

You may submit appeal requests by fax, email or mail:

• Fax: 1-877-495-3755
• Email: MedicarePlusBlueInpatientAppeals@bcbsm.com
• Mail:
  Medicare Plus Blue Inpatient Provider Appeal — Mail Code 1516
  Blue Cross Blue Shield of Michigan
  600 E. Lafayette Blvd.
  Detroit, MI 48226-2927

Time frames
A first-level appeal must be submitted within 45 days of the date of the denial decision. Include additional clarifying clinical information to support the request.

Medicare Plus Blue will notify the provider of our decision within 30 calendar days of receiving all necessary information.

A second-level appeal must be submitted within 21 days from the date of the first-level appeal decision. It must contain at least one of the following:

• New or clarifying information
• A clear statement of what the provider is requesting

If neither is included, Medicare Plus Blue isn’t obligated to review the second-level appeal request. We’ll notify the provider of the decision within 45 calendar days of receiving all necessary information. The plan’s second-level appeal decision is final.

Appeals outside the stated time frames
If you request appeals outside the time frames stated above, we’ll deny the first level of appeal request with a decision of untimely filing. We’ll then process the appeal request as a second level. The decision will be final.

At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or external review board.

Note: If an appeal request is received by Blue Cross outside the designated time frame, we’re not obligated to review the case.

Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and Trading Partner IDs don’t change.

Keep these items in mind when changes occur. You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Commercial pharmacy audits begin April 2019

Blue Cross Blue Shield of Michigan is using SCIO Health Analytics, an independent company, to conduct compliance audits on 2018 pharmacy claims.

The audits will be claim-specific and help ensure that paid claims were accurately billed according to Blue Cross and Blue Care Network pharmacy guidelines, as well as state and federal laws.

Please be prepared to share prescription records for review. After an audit, SCIO will send the findings letter and, if necessary, information on how to seek an appeal. Any audit recoveries will be paid to Blue Cross Blue Shield of Michigan as directed in the audit letter.

Pharmacies are required to comply with audit requests from Blue Cross, BCN or its agents according to the terms and conditions of the pharmacy network participation agreement.

Questions?
Contact your SCIO provider service representative at 1-866-628-3488, ext. 7414.

Here’s what you need to know about foot orthotic codes L3000-L3030

The method used to produce foot orthotic devices determines which procedure codes within this range are appropriate.

According to terminology used in the Healthcare Common Procedure Coding System Level II Manual:

• Codes L3000-L3020 describe a foot insert molded to a patient model. In this scenario, a cast is made of the patient’s foot or it’s scanned. Then, an exact model of the foot is made from the cast or scan and raw materials are heated and molded over the model of the foot. (Existing products that have been customized using pads, wedges or other additions or modifications don’t fit this definition.)
• Code L3030 describes a foot insert formed to patient’s foot. In this scenario, the heated material is molded directly over the patient’s foot.

Any foot orthotic insert that isn’t directly molded to a three-dimensional model of a specific patient’s foot or to the foot itself shouldn’t be billed using codes L3000-L3030.

The billing of these codes is subject to audit review and recovery.