Confusion Over Orthotics Coverage in New Jersey
Several days ago I received a panicky call from a New Jersey orthotic manufacturer. He stated that one of his clients (a DPM) called him, very concerned that Horizon Blue Cross Blue Shield of New Jersey was going to discontinue foot orthotic coverage as of January 1, 2027. I found this very interesting, as a New Jersey Law, enacted in 2025, mandates foot orthotic coverage in the state when the prescriber deemed it medically necessary. The law (cited here) provides very liberal coverage for foot orthotic coverage.
Prior to researching Horizon’s new policy, I had the good sense to think back to my days in podiatry school in the mid 1970s, when rumors constantly played havoc with our young impressionable minds. It seems that in podiatry these “vicious podiatric rumors” as we labeled them, would never end. And so, in 2026 they continue.
I informed my client to stay cool. Having completed the research, it appears that Horizon’s new policy is in fact in line with the 2025 law and does not eliminate or seriously reduce foot orthotic coverage. It does not apply to patients under 21 and applies to those with the following coverage:
—Paul Kesselman, DPM
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Diabetic Shoe Coding
Question: I have a patient that loves the diabetic shoes but does not like the custom inserts and would prefer the standard inserts that come with the shoe. Will Noridian/CGS DMERC pay for just the A5500....shoes only? Or do I need to provide at minimum A5512 heat molded pair of inserts to meet the coverage criteria?
Response from Codinghelpline.com:
The policy reads as follows: Medicare covers therapeutic shoes and inserts for persons with diabetes. This statutory benefit is limited to one pair of shoes and up to three pairs of inserts or shoe modifications per calendar year. The pairs they are referring to are not the blank inserts that come with the shoes. Is that what you are referring to, or are you referring to the heat-moldable inserts, which are not custom?
Technically, the patient would not be covered for any inserts if they are obtaining up to three other modifications (A5503-A5507). From a medical perspective, I would argue that the inserts are equally or more important than the shoes because of their offloading capabilities. Hence, depending on the patient, I would be wary of dispensing shoes alone without at least on pair of qualified inserts (custom milled or molded/or heat molded). Or, if the patient has custom orthotics that are appropriate and in good working order, those could be substituted for the inserts covered by Medicare.
—Paul Kesselman, DPM
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Scholl College Reunion Honors DPM Alum
The recent Scholl College reunion recognized Rick Evans, DPM ’71 and his wife Kathy Evans, who have very generously provided a series of scholarship gifts and matches in support of Scholl students and are “incredible leaders and supporters.”
Source: Rosalind Franklin University
Social Media Post of the Day
81% of physicians now use AI in their practices, the AMA found in its 2026 survey. That is more than double the 38% who said so in 2023.
Podiatry is moving too. When PM Pulse asked readers when new technology, AI included, would affect their staffing, 37% of the 123 who answered said it already has or will within a year.
For a practice that hasn't started yet, the hardest part is knowing where to begin. David G. Armstrong, DPM, PhD (@d.g.armstrong), has a clear answer: start where it hurts most. For nearly every practice, he says, that means documentation, and an ambient scribe is "the lowest-risk, highest-yield first move."
"Don't start with the shiniest tool; start with the deepest paper cut."
From there, his advice is practical.
How Confident Are You in Your Cybersecurity Setup?
Re: Looking for Answers: L3000 Denials
We are seeing the same issues when two of any DME is dispensed for both feet, reimbursing for one only and all billed with one line item each. This is Blue Cross Blue shield of Texas PPO. Does using one line with two units overide those new edits?
—George Bakatsas, DPM
As previously stated, the use of KX modifier should only be used if the policy states:
1) Foot orthotics are covered for …. diagnosis and the patient has that diagnosis, AND
2) There is no mention in the policy that they follow Medicare guidelines for DME coverage (or something like that), OR
3) There is no stipulation that the orthotics are only covered if placed into a shoe that is an integral part of a brace.
Numbers 2 and 3 are currently the center of recoupments for Anthem and other carriers. The last thing you want is to join this party and be accused of misinterpretation of the policy. In the Anthem and other cases, the national policy of the carrier may either state they are “following Medicare guidelines”—being interpreted as meaning foot orthotics are only covered when the orthotic is placed into a shoe that is an integral part of a brace. However, the local policy may usurp that, so be sure the carrier is following the correct policy.
As for your situation, if this is a system-wide issue affecting other foot orthotics in Texas, these are the steps I would take:
To read this entire response, click the button below. To submit a question or response, email [email protected].
—Paul Kesselman, DPM
From the Magazine—October ‘26 Preview
Developing a Thicker Skin
Do you have an employee who frequently has their feelings hurt, who seems to take everything personally, or who is prone to tears? Do you replay scenes from work in your head at night, beating yourself up for not handling or anticipating things better, or for making an honest mistake? Or do you or your employees find yourselves feeling hurt, embarrassed, or betrayed by a careless remark, a funny look, or the least bit of criticism? If so, you would all benefit greatly from having a thicker skin.
Keeping Staff Happy on a Tight Budget
Your best medical assistant has been with the practice for 12 years. She trains every new hire, knows every provider's preferences and keeps the morning schedule from falling apart. Then she sees your job posting for her own position and realizes the new hire will start within a dollar an hour of what she makes.
That is the kind of resignation practices can still prevent before 2027, and it is why we built a handbook for the administrators and owners who set staff pay.
Source: Physicians Practice
Poll Results: What Portion of Your Work is Routine Foot Care?
Under 20 percent: 22 percent |
20-40 percent: 19 percent |
40-60 percent: 22 percent |
60-80 percent: 23 percent |
More than 80 percent: 11 percent |
Total responses: 305 |
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PM Pulse Classified Ads
30-Year Podiatry Practice—Kansas City, Missouri
Priced below appraisal. Established hospital-campus practice with strong referrals and 25,000 patient records. Fully equipped with digital X-ray and EMR. Staff staying on. Open four days, with demand for five. Retiring physician will assist with transition. A rare turnkey opportunity. Confidential inquiries: [email protected]
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id: 2026-10-27-09:04:57:043t