CurrentColorado Rocky Mountain Health PlansPolicy N/A

Reimbursement for orthotics and specialty shoes

Defines UnitedHealthcare Community Plan's reimbursement rules for orthotics and specialty shoes (including diabetic and orthopedic shoes) billed on CMS-1500/UB04 forms for Medicaid products and applicable providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for orthotics and specialty shoes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit HCPCS codes with corresponding ICD-10 diagnosis codes at the claim line level; diabetic shoe codes must be billed with a diabetes diagnosis and orthopedic shoes must not be billed with a diabetes diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2distinct HCPCS code groups provided

Claim-levelICD-10 must be reported at claim line level

Indiana: 2/dayA5513 maximum frequency/day specified

ICD-10 Diabetic Listattachments

Reimbursement Criteria

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Reimbursement criteria for orthotics and specialty shoes

UnitedHealthcare Community Plan reimburses for orthotics and specialty shoes only when HCPCS codes and corresponding ICD-10 diagnoses meet the policy requirements below.

Submit an appropriate HCPCS code for diabetic shoes (A55xx series) or orthopedic shoes (L32xx–L32xx series) as listed in the policy.

ICD-10 diagnosis reporting: Report ICD-10 diagnosis codes at the claim line level on the claim for the submitted HCPCS code.

See Attachments: ICD-10 Diabetic Diagnosis Code List for accepted diabetes diagnoses.

ALL of the following

Diabetic shoe HCPCS codes must be submitted with a diabetes ICD-10 diagnosis from the Diabetes Diagnosis list (Attachments).
Orthopedic shoe HCPCS codes must NOT be submitted with a diabetes diagnosis from the Diabetes Diagnosis list; orthotic/orthopedic codes should be used instead when diabetes is present.
The policy states orthopedic shoe claims should not include a diabetes diagnosis as there are more appropriate codes to utilize.

ALL of the following

Submit HCPCS codes with corresponding ICD-10 diagnosis codes at the claim line level for consideration of reimbursement.
Claims for codes on the 'Diabetes Shoes' list should be submitted with a diagnosis from the 'Diabetes Diagnosis' list in the attachments section.

ALL of the following

Indiana-specific limit: HCPCS code A5513 has a maximum frequency of 2 per day.

Exclusions (billing stance): UnitedHealthcare Community Plan will not reimburse diabetic shoes or orthotics for patients without a diabetes diagnosis on the claim, and will not reimburse non-diabetic (orthopedic) shoes or orthotics billed with a diabetes diagnosis.

HCPCS Codes and State-specific Coding Rules

Diabetic Shoes HCPCS CodesHCPCSCovered

A5500	Diabetic depth-inlay shoe, first pair, per member
A5501	Diabetic depth-inlay shoe, second pair, per member
A5503	Diabetic depth-inlay shoe, third pair, per member
A5504	Diabetic extra-depth shoe, first pair, per member
A5505	Diabetic extra-depth shoe, second pair, per member
A5506	Diabetic extra-depth shoe, third pair, per member
A5507	Diabetic custom-molded shoe, first pair, per member
A5508	Diabetic custom-molded shoe, second pair, per member
A5510	Diabetic custom-molded shoe, third pair, per member
A5512	Diabetic custom-molded shoe, fourth pair, per member

1–10 of 12

1/2

Billing Notemixed

Note	Claims for codes on the 'Orthopedic Shoes' list should not be submitted with a diagnosis from the 'Diabetes Diagnosis' list in the attachments section.

State-specific Coding Rules

Indiana state exceptionHCPCS A5513 — maximum frequency/day (MFD) = 2 per day

Claim Submission and Billing Requirements

Documentation Required

Claim submission: HCPCS with corresponding ICD-10 at claim line; diabetes linkage for diabetic shoe codes

Submit the HCPCS code for the diabetic or orthopedic shoe on the claim with the corresponding ICD-10 diagnosis reported at the claim line level. Diabetic shoe HCPCS codes must be billed with a diabetes diagnosis from the Diabetes Diagnosis list; orthopedic shoe HCPCS codes must not be billed with a diabetes diagnosis on the claim line.

Diabetic shoe codes on the 'Diabetes Shoes' list require a diagnosis from the 'Diabetes Diagnosis' attachment to be reimbursable.
Report the ICD-10 diagnosis at the claim line level for the HCPCS procedure code to be considered for reimbursement.

Policy Definitions and Billing Distinctions

Reimbursement policy — scope and approach

Policy scopeApplies to UnitedHealthcare Community Plan Medicaid products and services reported on the CMS-1500 (or electronic equivalent).

Covered itemsReimbursement applies to orthotics and specialty shoes when billed with the appropriate HCPCS code and corresponding ICD-10 diagnosis.

Reimbursement approachClaims are reimbursed based on codes that correctly describe services; coding, claims processing rules, regulatory requirements and benefit design may affect reimbursement.

Claim form applicabilityPolicy applies to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent.

Diabetic vs Orthopedic shoe billing rule

Diabetic shoe billing requirementDiabetic shoe HCPCS codes must be submitted with a diabetes diagnosis from the Diabetes Diagnosis attachment list.

Orthopedic/non-diabetic shoe billing guidanceOrthopedic or non-diabetic shoe HCPCS codes must NOT be billed with a diabetes diagnosis on the claim; use the appropriate non-diabetic codes instead.

Diagnosis reporting levelICD-10 diagnosis codes must be reported at the claim line level and correspond to the HCPCS code submitted.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for orthotics and specialty shoes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

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