AOPA, APMA Send Letter to CMS About A-5513 Coding

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The American Orthotic & Prosthetic Association (AOPA) and the American Podiatric Medical Association (APMA) sent a joint letter to Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma expressing concern about the recent Durable Medical Equipment Medicare Administrative Contractors (DME MAC) coding clarification for Healthcare Common Procedure Coding System (HCPCS) code A-5513.

The letter suggests that CMS can solve the issue by instructing the DME MACs and the Pricing, Data Analysis and Coding contractor to be less restrictive in their interpretation of the code language for A-5513 or by asking the CMS HCPCS panel to consider a verbiage change that would allow providers to bill custom diabetic inserts as A-5513 without the requirement that the inserts be molded to a physical model of the patient's foot.

According to the coding clarification, in order to bill Medicare for a custom-fabricated diabetic insert using HCPCS code A-5513, a physical model of the patient's foot must be created and that the insert must then be molded over the physical model of the foot. The clarification further states that processes that use a virtual model to create a custom fabricated diabetic insert through direct milling or another manufacturing process do not meet the code language for A-5513. As a result, billing must use A-9270 which is a HCPCS code used to describe statutorily non-covered services.

The AOPA/APMA letter expresses concern that the overly strict interpretation of the descriptor language for A-5513 limits the use of advanced technologies such as direct milling and 3-D printing to produce diabetic inserts that may result in a more intimate fit for the patient, possibly leading to better outcomes. The letter also states that the relatively small annual Medicare expenditure for custom diabetic inserts when compared to the overall Medicare expenditure for the treatment of diabetes mellitus is minimal, and the result in any real savings to the Medicare program will have a negative impact on patient outcomes.