S98.129A — Partial traumatic amputation of unspecified great toe, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS under Final Rule 1713; claims without these and without compliance with LCD-related Standard Documentation Requirements (A55426) will be denied.
- An order is not required for a heel or sole replacement or for transfer of a shoe to a brace.
- Documentation created by an orthotist or prosthetist shall be considered part of the individual's medical record to support documentation created by the treating practitioner per Social Security Act §1834(h)(5).
- When billing prosthetic shoes (HCPCS L3250) and related items, include diagnosis code(s) to the highest level of specificity describing the condition that necessitates the prosthetic shoes on each claim.
Key Coverage Criteria
- Shoes, inserts, and modifications are covered when the shoe is an integral part of a covered leg brace described by HCPCS L1900, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2050, L2060, L2080, or L2090 and are medically necessary for proper functioning of the brace.
- Oxford shoes (HCPCS L3224, L3225) are covered when they are an integral part of a covered brace and are medically necessary for the brace's function.
- Other shoes (e.g., high top, depth inlay, or custom non-diabetic shoes; HCPCS L3649) are covered when they are an integral part of a covered brace and medically necessary for proper function of the brace.
- Inserts, modifications, heel replacements, sole replacements, and shoe transfers (HCPCS L3000–L3595 range and specific codes L3455, L3460, L3530, L3540, L3600–L3640 as listed) are covered when placed on a shoe that is an integral part of a covered brace and are medically necessary for proper brace function.
- Heel replacements (HCPCS L3455, L3460), sole replacements (HCPCS L3530, L3540), and shoe transfers (HCPCS L3600, L3610, L3620, L3630, L3640) are covered when they involve shoes on a covered brace.
- Therapeutic shoes, inserts, and modifications for selected beneficiaries with diabetes for prevention or treatment of diabetic foot ulcers are covered under a separate medical policy (Therapeutic Shoes for Persons with Diabetes) and use different A‑codes.
1 Active Policy
A52481 — Orthopedic Footwear - Policy Article
J19
Related Codes
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