The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) released information about the correct coding of devices used by beneficiaries who need accommodation for missing toes. Correct coding is determined by which benefit category is used for reimbursement. Beneficiaries who have diabetes and receive therapeutic footwear and shoe inserts for the protective function related to the management of diabetes would be coded utilizing Healthcare Common Procedure Coding System (HCPCS) codes such as A-5512, A-5513, or A-5514. However, beneficiaries with or without diabetes that require standing balance and toe-off support to accommodate missing toes would receive devices related to the prosthetic benefit which are coded with L-code(s) such as L-5000, L-5010, and L-5020.
HCPCS codes are related to the Medicare benefit category and the use of codes from another benefit category is incorrect coding, according to the publication.
- L-5000 (partial foot, shoe insert with longitudinal arch, toe filler) describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe) or the forefoot, L-5000 inserts are designed to provide standing balance and toe off support for improved gait. L5000 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.
- L-5010 (partial foot, molded socket, ankle height, with toe filler) describes a partial foot device including a molded socket for the residual limb with a proximal height terminating at the ankle or extending proximally as needed to achieve appropriate support and function. L-5010 is inclusive of a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe), or the forefoot, L-5010 devices are designed to provide standing balance and toe off support for improved gait. All closures are included, any type. L5010 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.
- L-5020 (partial foot, molded socket, tibial tubercle height, with toe filler) describes a partial foot device including a molded socket for the residual limb with a proximal height terminating at/near tibial tubercle to achieve appropriate support and function. L-5020 is inclusive of a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe), or the forefoot, L-5020 devices are designed to provide standing balance and toe off support for improved gait. All closures are included, any type. L-5020 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.
Shoe inserts for the protective function related to the management of the individual’s diabetes:
- A-5512 (for diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each)
- 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)
- A-5514 (for diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, 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)
For a beneficiary with diabetes and missing toes or a forefoot, the DME MACs advised suppliers of the two options for billing inserts/devices:
- Option 1: For beneficiaries with diabetes who do not require the rigidity and support afforded by code L-5000 (e.g., beneficiaries missing digits excluding the hallux), suppliers must bill code A-5513 or A-5514 for an insert appropriately custom-fabricated to accommodate the missing digit(s).
- Option 2: For beneficiaries missing the hallux or a forefoot that require rigidity and support for effective gait, suppliers must bill for a device described by L-code(s) such as L-5000, for an insert appropriately custom-fabricated to accommodate the missing digit(s) or forefoot as well as providing the foot-protective functions required for a person with diabetes. Codes A-5512, A-5513, or A-5514 may not be billed in addition to the L-code(s) to fully describe the device.
The Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 140 allows for a pair of shoes for a person with diabetes. The therapeutic shoes that are provisioned in the management of the individual’s diabetes provides for a pair of diabetic shoes even if only one foot suffers from diabetic foot disease. Each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected.
The DME MACs encouraged suppliers to review both the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination and related Policy Article and the Lower Limb Prostheses Local Coverage Determination and related Policy Article on the Medicare Coverage Database for additional information on the coverage, coding and documentation of these items.
