Re: Looking for Answers: L3000 Denials

Sorry for the confusion with my initial response. There was a typo. My bad! With respect to the initial explanation where the "NU" modifier is present, please eliminate the "NU" modifier. The NU modifier is defined as “New Equipment.” This modifier is not needed to refile the claim.

Once again, with respect to the Fix:
Leave Line 1 alone. On Line 2 (L3000-LT), append modifier XS (Separate Structure) or modifier 59 (Distinct Procedural Service). 

The Sequence: 
Line 1: (Already Paid): L3000-RT
Line 2 (The Correction): L3000-LT, XS (or L3000-LT, 59)

Regarding the XS and the 59 modifiers as “ONLY FOR PROCEDURES,” No, modifier XS and modifier 59 are not restricted exclusively to surgical or medical procedures.

According to current claim coding practices, Blue Cross and Blue Shield of Texas (BCBSTX) Modifier Reference Policy (CPCP023), both modifier XS (Separate Structure) and modifier 59 (Distinct Procedural Service) can be appended to HCPCS code L3000 (Custom Foot Orthotics) under specific anatomical and billing conditions. However, they should only be used to distinguish distinct anatomical locations or non-overlapping services on the same date of service, rather than routinely combined. The refiling of Line 2 above is an example of the appropriate use of either of these two modifiers.

Ironically, here is an example that was provided:
If you are billing for a bilateral pair of custom orthotics on separate claim lines (e.g., Line 1: L3000-RT; Line 2: L3000-LT), some claim-scrubbing systems trigger a duplicate charge edit for the second line. In this specific scenario, appending modifier XS (or modifier 59 if your system prefers it) to Line 2 (L3000-LT-XS) signals to BCBSTX that the second item is a completely separate structure and not a duplicate billing error.

With respect to S0395-RT and S0395-LT, HCPCS Level II code S0395 is defined as the following: impression casting of a foot performed by a practitioner who is not the manufacturer of the custom orthotic.

Not all health insurance contractors reimburse for this HCPCS Level II code. You are fortunate that BCBS of Texas did reimburse. Since they only reimbursed for the RT foot, it is my opinion that in order to attempt to be paid for the LT foot (S0395-LT), I would refile a claim for S0395-LT as described above for L-3000-LT.

The Sequence:
Line 1: (Already Paid): S0395-RT
Line 2 (The Correction): S0395-LT, XS (or S0395- LT, 59). 

This is my opinion and suggestion. 

—Michael G. Warshaw, DPM, CPC