MEDICAL POLICY: Podiatry Shoes and Inserts (Orthotic Foot Inserts)

POLICY . . . . . . . . PG-0238 EFFECTIVE . . . . . .03/15/09 LAST REVIEW . . . 04/08/14 MEDICAL POLICY: Podiatry Shoes and Inserts (Orthotic Foot Ins...
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POLICY . . . . . . . . PG-0238 EFFECTIVE . . . . . .03/15/09 LAST REVIEW . . . 04/08/14

MEDICAL POLICY: Podiatry Shoes and Inserts (Orthotic Foot Inserts)

GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

DESCRIPTION Diabetic Shoes and Inserts (procedure codes A5500-A5513) are for the prevention or treatment of diabetic foot ulcers. These are not prescribed unless the member has a diabetic condition that has been documented in their medical record. They are covered under a member’s DME benefit and not under the orthotic benefit. A member will not be supplied any other type of orthotic when they have the need for a diabetic shoe and or insert. The exception would be inserts for missing toes or partial foot amputation. Unit limits apply to these items. Orthotic Shoes and Inserts (procedure codes L3000–L3649) are defined and dispensed as a benefit provided independently of diabetic shoes and inserts. These require a specific diagnosis to support medical necessity, and the member must have the limited podiatry orthotic benefit. These are considered medically necessary only in these limited circumstances:  If they are an integral part of a leg brace that is medically necessary  Heel replacements, sole replacements, and shoe transfers involving shoes on a medically necessary leg brace  Inserts and other shoe modifications (e.g., wedges, arch supports and other additions) if they are on a shoe that is an integral part of a leg brace for proper functioning of the brace  If they are an integral part of a prosthesis for individuals with a partial foot amputation If a member has a complete orthotic rider benefit, many medical conditions (listed below) related to an illness and/or injury would support the medical necessity of podiatry shoes and supplies. These medical conditions do not support medical necessity for a member unless their policy includes an orthotic benefit.  Acute plantar fasciitis  Calcaneal spurs (heel spurs)  Calcaneal bursitis (acute or chronic)  Neurologically impaired feet including neuroma, tarsal tunnel syndrome, ganglionic cyst, and neuropathies involving the feet, and including those associated with peripheral vascular disease, diabetes, carcinoma, drugs, toxins, and chronic renal disease  Inflammatory conditions (i.e., sesamoiditis, sub-metatarsal bursitis, synovitis, tenosynovitis, synovial cyst, osteomyelitis, and plantar fascial fibromatosis)  Acute sport-related injuries, including diagnosis-related to inflammatory problems (e.g., bursitis, tendonitis)  Musculoskeletal/arthropathic deformities including deformities of the joint or skeleton that impairs walking in a normal shoe (e.g. bunions, hallux valgus, talipes deformities, pes deformities, anomalies of toes)  Medial osteoarthritis of the knee (lateral wedge insoles)  Vascular conditions including ulceration, poor circulation, peripheral vascular disease, Buerger's disease (thromboangiitis obliterans), and chronic thrombophlebitis It is the provider's responsibility to assure that any orthotic or prosthetic device continues to fit properly for three months from the date of dispensing. Any modifications, adjustments, or replacements within the three months are the responsibility of the provider that supplied the item, and no additional charge will be allowed to the department or the consumer. The provision of these services by another provider will not be separately reimbursed. Shoes are considered not medically necessary when they are put on over a partial foot prosthesis, or other lower extremity prosthesis that is attached to the residual limb by mechanisms, other than being an integral part of the prosthesis. A matching shoe that is not attached to a brace, and items related to that shoe are, considered not medically necessary.

Stock orthotics (i.e., over-the-counter and/or off-the-shelf items that do not require a physician’s prescription) are not covered under the orthotic benefit. These include, but are not limited to  Arch supports, other foot support devices, and foot orthotics, including transferrable shoe inserts  Elastic stockings  Garter belts  Orthopedic shoes (except when either one or both shoes are an integral part of a leg brace) A foot pressure off-loading supportive device (procedure code A9283) will be denied. Procedure L3649 will always deny for invoice and chart review to assist in evaluation for reimbursement. This will pend to be reviewed if documentation is submitted with the claim. If it was not submitted with the claim, it will be denied for invoice and the detailed description with notes to support the need/medical necessity of the item. The evaluation of the patient, measurement and/or casting, and fitting of the orthotic are included in the allowance for the orthotic. There is no separate payment for these services.

POLICY Podiatry Shoes and Inserts (Orthotic Foot Inserts) do not require prior authorization. (See terms of coverage below.) HMO, PPO, Individual Marketplace, Elite When a member is assigned an orthotic benefit, they are given the following benefit choices; 1. No orthotic benefit – none of the orthotic items within this section are considered covered, no matter what the medical condition and/or the diagnosis is. Orthotics will never be covered. 2. Covered orthotic benefit – all the orthotic items within this section are considered covered no matter what the medical condition and/or the diagnosis is. All orthotics are allowed without any medical guidelines applied. 3. Limited orthotic benefit – this follows the guidelines above in which the orthotic inserts (L3000-L3030, L3040-L3090, L3170) are covered based on the medical condition and diagnosis reported. If member  does not have an orthotic benefit rider  has a limited orthotic rider in which there is no medically supporting diagnosis  has a limited orthotic rider, but the item is never considered a covered item all the orthotic shoe and insert items will be denied. Upon appeal, if a member has diabetes, they will be supplied the non-benefit orthotics (procedures A5500-A5508, A5512-A5513). Procedures L3000-L3649 will continue to deny. Procedures A5510 and A9283 are non-covered. The limited benefit are procedures L3000-3030, L3040-L3090 and L3170 and they do require the diagnosis indicating medical necessity. The diagnosis should indicate a partial or full amputation where a brace is being used by the member. Replacements are provided usually after the normal life span (wear and tear, malfunction of the device, and\or for growth adjustments). There are a few shoes and inserts that are not covered no matter what the diagnosis even if the member has complete coverage. These include procedure codes L3031, L3160, L3201-L3222, L3230-L3265, L3320, and L3485. It is expected the member would provide their own shoe(s) and add the parts allowed under their benefit. Advantage Orthopedic shoes are covered only if the shoe is an integral part of a brace with exceptions of molded, mis-mated, and club foot shoes, or shoes for children under the age of eight, diagnosed as having a deformity or condition. To accommodate growth for children under the age of eight, a maximum of three pairs of shoes are allowed every year. For children over eight and adults, a maximum of two pairs of shoes are allowed every year. All orthotics follow the limits set by the state. The limits reflect a single extremity, and have been increased due to claims processing limitations when dispensed for two extremities. Only select products with select benefit limits, and with unit limits applied, will be allowed.

NOT COVERED A5510, A9283, L3003, L3031, L3070, L3080, L3090, L3212, L3213, L3214, L3250, L3254, L3255, L3260, L3265, L3330, L3450, L3485, L3560, L3590, L3640 COVERED (Limits may apply) A5500, A5501, A5503-A5508, A5512, A5513, L3000-L3002, L3010, L3020, L3030, L3040, L3050, L3060, L3100, L3140, L3150, L3160, L3170, L3201-L3209, L3211, L3215-L3221, L3222, L3224, L3225, L3230, L3251-L3253, L3257, L3300, L3310, L3320, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3455, L3460, L3465, L3470, L3480, L3500, L3510, L3520, L3530, L3540, L3550, L3570, L3580, L3595,` L3600, L3610, L3620, L3630, L3649

The allowed reimbursement amount for any orthotic listed includes, but is not limited to the following;  Labor  Casting  Fitting or measuring fees  Charges for travel  Charges for shipping and mailing Casting and casting supplies will always be denied. For the diabetic member, inserts for missing toes or partial foot amputation should be reported with procedures L5000 or L5999, whichever is applicable.

CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

HCPCS CODES A5500 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF OFF-THESHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI- DENSITY INSERT(S), PER SHOE A5501 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF SHOE MOLDED FROM CAST(S) OF PATIENT’S FOOT (CUSTOM MOLDED SHOE), PER SHOE A5503 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PER SHOE A5504 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOE A5505 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOE A5506 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH OFF-SET HEEL(S), PER SHOE A5507 FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE A5508 FOR DIABETICS ONLY, DELUXE FEATURE OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE A5510 FOR DIABETICS ONLY, DIRECT FORMED, COMPRESSION MOLDED TO PATIENT’S FOOT WITHOUT EXTERNAL HEAT SOURCE, MULTIPLE-DENSITY INSERT(S) PREFABRICATED, PER SHOE A5512 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OF SHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER), PREFABRICATED, EACH A5513 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT’S FOOT, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EA A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH L3000 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, EACH L3001 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH L3002 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH L3003 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACH L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT, EACH L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL SUPPORT, EACH L3030 FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH L3031 FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH

L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470

FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ METATARSAL, EACH FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATARSAL, EACH HALLUS-VALGUS NIGHT DYNAMIC SPLINT FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES FOOT, ABDUCTION ROTATATION BAR, WITHOUT SHOES FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, EACH ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILD ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIOR SURGICAL BOOT, EACH, INFANT SURGICAL BOOT, EACH, CHILD SURGICAL BOOT, EACH, JUNIOR BENESCH BOOT, PAIR, INFANT BENESCH BOOT, PAIR, CHILD BENESCH BOOT, PAIR, JUNIOR ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE, EACH FOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACH FOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABRICATED, EACH FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH NON-STANDARD SIZE OR WIDTH NON-STANDARD SIZE OR LENGTH ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZE SURGICAL BOOT/SHOE, EACH PLASTAZOTE SANDAL, EACH LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH LIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCH LIFT, ELEVATION, METAL EXTENSION (SKATE) LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH LIFT, ELEVATION, HEEL, PER INCH HEEL WEDGE, SACH HEEL WEDGE SOLE WEDGE, OUTSIDE SOLE SOLE WEDGE, BETWEEN SOLE CLUBFOOT WEDGE OUTFLARE WEDGE METATARSAL BAR WEDGE, ROCKER METATARSAL BAR WEDGE, BETWEEN SOLE FULL SOLE AND HEEL WEDGE, BETWEEN SOLE HEEL, COUNTER, PLASTIC REINFORCED HEEL, COUNTER, LEATHER REINFORCED HEEL, SACH CUSHION TYPE HEEL, NEW LEATHER, STANDARD HEEL, NEW RUBBER, STANDARD HEEL, THOMAS WITH WEDGE HEEL, THOMAS EXTENDED TO BALL

L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649

HEEL, PAD AND DEPRESSION FOR SPUR HEEL, PAD, REMOVABLE FOR SPUR ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER ORTHOPEDIC SHOE ADDITION, SOLE, HALF ORTHOPEDIC SHOE ADDITION, SOLE, FULL ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD ORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOE ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS) ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER ORTHOPEDIC SHOE ADDITION, MARCH BAR TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENNIS BROWNE SPLINT (RIVETON), BOTH SHOES ORTHOPEDIC SHOE, MODIFICATION, ADDITION OR TRANSFER, NOT OTHERWISE SPECIFIED

ICD-9-CM CODES (only applies to the Limited Orthotic Benefit) 755.31 755.38 755.39 895 895.1 896 896 896.1 896.2 896.3

Transverse deficiency of lower limb Longitudinal deficiency, tarsals or metatarsals, complete or partial (with or without incomplete phalangeal deficiency) Reduction deformities of lower limb, congenital, longitudinal deficiency, phalanges, complete or partial Traumatic amputation of toe(s) (complete) (partial), without mention of complication Traumatic amputation of toe(s) (complete) (partial), complicated Traumatic amputation of foot (complete) (partial), unilateral, without mention of complication Traumatic amputation of foot (complete) (partial) Traumatic amputation of foot (complete) (partial), unilateral, complicated Traumatic amputation of foot (complete) (partial), bilateral, without mention of complication Traumatic amputation of foot (complete) (partial), bilateral, complicated

ICD-10-CM CODES; EFFECTIVE 10/01/2015 (only applies to the Limited Orthotic Benefit) Q72.00 Q72.01 Q72.02 Q72.03 Q72.30 Q72.31 Q72.32 Q72.33 Q72.70 Q72.71 Q72.72 Q72.73 S98.011A S98.011D S98.011S S98.012A S98.012D S98.012S S98.019A S98.019D S98.019S S98.021A S98.021D S98.021S S98.022A S98.022D S98.022S

Congenital complete absence of unspecified lower limb Congenital complete absence of right lower limb Congenital complete absence of left lower limb Congenital complete absence of lower limb, bilateral Congenital absence of unspecified foot and toe(s) Congenital absence of right foot and toe(s) Congenital absence of left foot and toe(s) Congenital absence of foot and toe(s), bilateral Split foot, unspecified lower limb Split foot, right lower limb Split foot, left lower limb Split foot, bilateral Complete traumatic amputation of right foot at ankle level, initial encounter Complete traumatic amputation of right foot at ankle level, subsequent encounter Complete traumatic amputation of right foot at ankle level, sequela Complete traumatic amputation of left foot at ankle level, initial encounter Complete traumatic amputation of left foot at ankle level, subsequent encounter Complete traumatic amputation of left foot at ankle level, sequela Complete traumatic amputation of unspecified foot at ankle level, initial encounter Complete traumatic amputation of unspecified foot at ankle level, subsequent encounter Complete traumatic amputation of unspecified foot at ankle level, sequela Partial traumatic amputation of right foot at ankle level, initial encounter Partial traumatic amputation of right foot at ankle level, subsequent encounter Partial traumatic amputation of right foot at ankle level, sequela Partial traumatic amputation of left foot at ankle level, initial encounter Partial traumatic amputation of left foot at ankle level, subsequent encounter Partial traumatic amputation of left foot at ankle level, sequela

S98.029A S98.029D S98.029S S98.111A S98.111D S98.111S S98.112A S98.112D S98.112S S98.119A S98.119D S98.119S S98.121A S98.121D S98.121S S98.122A S98.122D S98.122S S98.129A S98.129D S98.129S S98.131A S98.131D S98.131S S98.132A S98.132D S98.132S S98.139A S98.139D S98.139S S98.141A S98.141D S98.141S S98.142A S98.142D S98.142S S98.149A S98.149D S98.149S S98.211A S98.211D S98.211S S98.212A S98.212D S98.212S S98.219A S98.219D S98.219S S98.221A S98.221D S98.221S S98.222A S98.222D S98.222S S98.229A S98.229D S98.229S S98.311A S98.311D S98.311S S98.312A S98.312D

Partial traumatic amputation of unspecified foot at ankle level, initial encounter Partial traumatic amputation of unspecified foot at ankle level, subsequent encounter Partial traumatic amputation of unspecified foot at ankle level, sequela Complete traumatic amputation of right great toe, initial encounter Complete traumatic amputation of right great toe, subsequent encounter Complete traumatic amputation of right great toe, sequela Complete traumatic amputation of left great toe, initial encounter Complete traumatic amputation of left great toe, subsequent encounter Complete traumatic amputation of left great toe, sequela Complete traumatic amputation of unspecified great toe, initial encounter Complete traumatic amputation of unspecified great toe, subsequent encounter Complete traumatic amputation of unspecified great toe, sequela Partial traumatic amputation of right great toe, initial encounter Partial traumatic amputation of right great toe, subsequent encounter Partial traumatic amputation of right great toe, sequela Partial traumatic amputation of left great toe, initial encounter Partial traumatic amputation of left great toe, subsequent encounter Partial traumatic amputation of left great toe, sequela Partial traumatic amputation of unspecified great toe, initial encounter Partial traumatic amputation of unspecified great toe, subsequent encounter Partial traumatic amputation of unspecified great toe, sequela Complete traumatic amputation of one right lesser toe, initial encounter Complete traumatic amputation of one right lesser toe, subsequent encounter Complete traumatic amputation of one right lesser toe, sequela Complete traumatic amputation of one left lesser toe, initial encounter Complete traumatic amputation of one left lesser toe, subsequent encounter Complete traumatic amputation of one left lesser toe, sequela Complete traumatic amputation of one unspecified lesser toe, initial encounter Complete traumatic amputation of one unspecified lesser toe, subsequent encounter Complete traumatic amputation of one unspecified lesser toe, sequela Partial traumatic amputation of one right lesser toe, initial encounter Partial traumatic amputation of one right lesser toe, subsequent encounter Partial traumatic amputation of one right lesser toe, sequela Partial traumatic amputation of one left lesser toe, initial encounter Partial traumatic amputation of one left lesser toe, subsequent encounter Partial traumatic amputation of one left lesser toe, sequela Partial traumatic amputation of one unspecified lesser toe, initial encounter Partial traumatic amputation of one unspecified lesser toe, subsequent encounter Partial traumatic amputation of one unspecified lesser toe, sequela Complete traumatic amputation of two or more right lesser toes, initial encounter Complete traumatic amputation of two or more right lesser toes, subsequent encounter Complete traumatic amputation of two or more right lesser toes, sequela Complete traumatic amputation of two or more left lesser toes, initial encounter Complete traumatic amputation of two or more left lesser toes, subsequent encounter Complete traumatic amputation of two or more left lesser toes, sequela Complete traumatic amputation of two or more unspecified lesser toes, initial encounter Complete traumatic amputation of two or more unspecified lesser toes, subsequent encounter Complete traumatic amputation of two or more unspecified lesser toes, sequela Partial traumatic amputation of two or more right lesser toes, initial encounter Partial traumatic amputation of two or more right lesser toes, subsequent encounter Partial traumatic amputation of two or more right lesser toes, sequela Partial traumatic amputation of two or more left lesser toes, initial encounter Partial traumatic amputation of two or more left lesser toes, subsequent encounter Partial traumatic amputation of two or more left lesser toes, sequela Partial traumatic amputation of two or more unspecified lesser toes, initial encounter Partial traumatic amputation of two or more unspecified lesser toes, subsequent encounter Partial traumatic amputation of two or more unspecified lesser toes, sequela Complete traumatic amputation of right midfoot, initial encounter Complete traumatic amputation of right midfoot, subsequent encounter Complete traumatic amputation of right midfoot, sequela Complete traumatic amputation of left midfoot, initial encounter Complete traumatic amputation of left midfoot, subsequent encounter

S98.312S S98.319A S98.319D S98.319S S98.321A S98.321D S98.321S S98.322A S98.322D S98.322S S98.329A S98.329D S98.329S S98.911A S98.911D S98.911S S98.912A S98.912D S98.912S S98.919A S98.919D S98.919S S98.921A S98.921D S98.921S S98.922A S98.922D S98.922S S98.929A S98.929D S98.929S

Complete traumatic amputation of left midfoot, sequela Complete traumatic amputation of unspecified midfoot, initial encounter Complete traumatic amputation of unspecified midfoot, subsequent encounter Complete traumatic amputation of unspecified midfoot, sequela Partial traumatic amputation of right midfoot, initial encounter Partial traumatic amputation of right midfoot, subsequent encounter Partial traumatic amputation of right midfoot, sequela Partial traumatic amputation of left midfoot, initial encounter Partial traumatic amputation of left midfoot, subsequent encounter Partial traumatic amputation of left midfoot, sequela Partial traumatic amputation of unspecified midfoot, initial encounter Partial traumatic amputation of unspecified midfoot, subsequent encounter Partial traumatic amputation of unspecified midfoot, sequela Complete traumatic amputation of right foot, level unspecified, initial encounter Complete traumatic amputation of right foot, level unspecified, subsequent encounter Complete traumatic amputation of right foot, level unspecified, sequela Complete traumatic amputation of left foot, level unspecified, initial encounter Complete traumatic amputation of left foot, level unspecified, subsequent encounter Complete traumatic amputation of left foot, level unspecified, sequela Complete traumatic amputation of unspecified foot, level unspecified, initial encounter Complete traumatic amputation of unspecified foot, level unspecified, subsequent encounter Complete traumatic amputation of unspecified foot, level unspecified, sequela Partial traumatic amputation of right foot, level unspecified, initial encounter Partial traumatic amputation of right foot, level unspecified, subsequent encounter Partial traumatic amputation of right foot, level unspecified, sequela Partial traumatic amputation of left foot, level unspecified, initial encounter Partial traumatic amputation of left foot, level unspecified, subsequent encounter Partial traumatic amputation of left foot, level unspecified, sequela Partial traumatic amputation of unspecified foot, level unspecified, initial encounter Partial traumatic amputation of unspecified foot, level unspecified, subsequent encounter Partial traumatic amputation of unspecified foot, level unspecified, sequela

REVISION HISTORY EXPLANATION 07/1/2010: Updated 04/08/14: ICD-10 Codes added from ICD-9 conversion. Policy reviewed and updated to reflect most current clinical evidence. Approved by Medical Policy Steering Committee as revised.

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid http://jfs.ohio.gov/ American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.