CMS Proposes Reduction in Reimbursement for Direct-milled Inserts

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The Centers for Medicare and Medicaid Services (CMS) has proposed that inserts fabricated using a direct-milling process would be reimbursed at a rate approximately 14 percent lower than those that were molded over a physical model of the patient's foot. At an open-door forum on November 28, CMS officials outlined plans to revise the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) quality standards for custom-fabricated inserts to account for advances in technology that allow them to be direct milled using computer-assisted software. However, because of the difference in technology, CMS proposed that the inserts be billed under a new code, rather than under the existing Healthcare Common Procedure Coding System  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]) code.

CMS has indicated that it intends to finalize the proposed changes by January 1, 2018.

The American Orthotic & Prosthetic Association (AOPA) participated in a CMS forum on November 28 about the proposed revision to DMEPOS quality standards that would expand the definition of the term "molded to patient model" to include diabetic inserts that are custom fabricated from digital or virtual models using a direct-milling process. During the forum, AOPA said that it expressed its concern regarding a document published by CMS prior to the forum that mentioned that using a direct-milling process would lead to a lower reimbursement rate than those that were molded over a physical model of the patient's foot.

"The Medicare reimbursement manual says that when you explode codes, both codes will have the same value," Tom Fise, executive director of AOPA, told HME News. "How does CMS get to magically say they are going to reduce the payment by 14 percent because you are creating the same product, but you are not using the same manufacturing process?"

AOPA questioned "the ‘toll' on providers who chose to provide direct-milled inserts that are identical to inserts fabricated using the older technology," at the forum and followed up with a letter to CMS reiterating the question and challenging the response provided by CMS officials at the forum. AOPA said it will incorporate its concerns into its full comments, and encourages other interested parties to submit comments through its website or by email at

To read AOPA's letter regarding the open-door forum, visit its website.