The Centers for Medicare & Medicaid Services (CMS) has established the fee structure for K-0903/A-5513. The fee schedule for K-0903, a temporary Healthcare Common Procedure Coding System (HCPCS) code, effective April 1, that describes custom-fabricated, direct-milled diabetic inserts has been set at the same amount as the current Medicare fee schedule for A-5513 ($43.56 for most states), which describes custom-fabricated diabetic inserts that are fabricated over a positive model of the patient’s foot.
The American Orthotic & Prosthetic Association (AOPA) issued a statement saying it was pleased with the outcome. The issue began with a decision, first highlighted by the Pricing, Data and Coding (PDAC) contractor last summer that diabetic shoe inserts fabricated using scanning devices and direct milling did not meet the precise words of the A-5513 code, which referenced the process as molded over a model of the patient’s foot. A coding verification notification was initiated by PDAC to focus on the process used.
An ensuing debate began as AOPA partnered with the American Podiatric Medical Association (APMA) and wrote a letter of concern that the strict interpretation of the descriptor language for A-5513 limited the use of advanced technologies such as direct milling and 3D printing to produce diabetic inserts that may have resulted in a more intimate fit for the patient. In addition, this code, vital to protecting diabetic patients, has declined in utilization by 14 percent in the prior three years, largely because of unreasonable reimbursement cuts, according to AOPA.
At an open-door forum in November 2017, CMS announced they agreed that the processes were equivalent, but also said that the scanned device required less work, and they expected to reduce the fee by about $7 for direct milled inserts. As a result of Congressional pressure, however, the fee decision was ultimately shifted to top CMS administrators, who eventually decided that as the processes were essentially equivalent, the fee also needed to be identical.
Since A-5513 is not the only code where scanning processes have evolved, AOPA said it is hopeful that this decision sets the right precedent for the agency. According to AOPA, the advocacy victory is important, not only for what it represents for providers of diabetic inserts, but also for the precedent that it sets for future issues involving the use of scanning and other technology to create alternate manufacturing processes in orthotics and prosthetics.