07/25/2022

DMERC- Denial for L3000-Not Part of Leg Brace

L3000 when billed to DMERC is denied for not being part of a leg brace however, we have always billed L3000 to Medicare DMERC modifier Rt Lt and these claims have always been paid. Also under your question and answer section it has L3000 with definition and it doesnt say anything about a leg brace. Am I missing something?

When billing traditional Medicare (DMERC), there are no circumstances where orthotics are covered as a standalone item. Per prior Medicare LCD Policies and the current coding article on orthotics (see links below), HCPCS code L3000 is only covered if it is a component of a brace. If orthotics are dispensed to a patient by themselves, Medicare considers the item a “statutorily excluded benefit” that are never covered under any conditions if they are not part of a leg brace. If a patient has secondary insurance, they may cover the balance not paid by Medicare. If these claims have been paid in the past by Medicare, it was done in error and should be refunded as soon as possible to the DMERC carrier. There is no mention of the leg brace in the definition of HCPCS L3000 because this code is for orthotics only- a leg brace is composed of multiple HCPCS code that represents the device that is patient specific.

LCD - Orthopedic Footwear (L33641) (cms.gov)

Article - Orthopedic Footwear - Policy Article (A52481) (cms.gov)