DME MACs Clarify Requirements for A-5513

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The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication on July 13 that addressed the proper use of diabetic shoe insert Healthcare Common Procedure Coding System (HCPCS) code A-5513 (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, each). According to the publication, diabetic inserts billed using A-5513 must be molded over an actual model of the patient's foot. The use of a virtual, generic, or electronic model in custom fabrication without creating a physical model of the patient's foot does not meet the code descriptor. Inserts fabricated with virtual, generic, or electronic models must be billed with code A-9270 (noncovered item or service).

The joint publication states the requirement as follows: 

"The HCPCS code narrative passage, ‘…custom molded from model of patient's foot…' requires that a physical model of the beneficiary's foot must be produced and that the insert be individually molded to the physical model. Some manufacturers do not produce an actual physical model of the individual beneficiary's foot. Instead, a CAD-CAM system creates an electronic positive model derived from specific patient measurements, i.e. a ‘virtual model', or use a library of generic models to fabricate an insert. Inserts produced using these or similar techniques must not be coded as A-5513 for Medicare billing."

To read the announcement, visit www.cgsmedicare.com/articles/cope3771.html.