It seems that the consensus is the toe filler is treated more like a prosthetic device (vs. a foot orthotic) and has to fall under stricter criteria to be replaced. So 1 per year instead of 3 like custom foot orthotics. One clinician did bring up an interesting point about switching the toe filler onto a new custom FO after the 4 month span but I’m not sure how that would be repeatable time after time (with a nice looking result, anyway!).
Responses are listed below. At least now I have a better explanation for the patient who was asking!
Jacqueline Schmit, MS, CP Certified Prosthetist
I believe it is only 1 partial foot per year, even though you can do 3 regular diabetic inserts for the sound side.
I don’t think you can get 3 toe fillers in one year, remember Toe fillers are prosthetics so they do not fall under the same useful lifetime rules as simple foot orthotics. You have to establish medical need for more than one and since it is a prosthesis it will be much harder to prove the need for more than one. I do not have any of this in writing but you can also call Devon at AOPA and he can advise you more appropriately.
L5000 is not part of the therapeutic shoes benefit but part of the prosthetic benefit. An L5000 would be replaced if it is medically necessary to do so.
Diabetic Inserts & Partial Feet Inserts (09/12/2012)
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have issued guidance on how to bill for diabetic inserts (A5512 and A5513) when the patient also requires a partial foot insert (L5000).
The L5000 includes a rigid longitudinal arch support and includes the addition of materials to fill the void of the missing digits, and the addition of softer materials in areas where the residual limb makes contact with the insert. The L5000 is designed to provide standing balance and toe off support for the patient to improve their gait. Diabetic inserts are designed with multiple layers of materials varying in destiny to provide a protective function for the foot and is part of the patient’s diabetes management efforts.
If the patient has diabetes and does not require the extra rigidity and support provided by the L5000, because they are only missing toes; excluding the big toe (hallux), you may only bill for the A5513 (custom diabetic insert) and not the L5000. In this scenario the customization of the A5513 includes the addition of materials to replace the missing digits.
If the patient has diabetes and requires the extra rigidity and support provided by the L5000, because they are missing the hallux or forefoot you may only bill for the L5000 and you may not also bill for an A5512 or A5513. In this scenario the provision of the L5000 includes the addition of materials to replace the missing digits, and the materials added to create the protective function as part of the patient’s diabetes management.
Everything I have heard and what I go by personally is one L5000 per medical necessity. Never had any issues with that guideline. I replace when there is limb change, worn out materials, soiled materials, revisions, etc. They are not looked at like inserts and they are considered a prosthesis, hence the L5XXX coding.
The 3 inserts you refer applies to the Therapeutic Shoe Bill, the L500 Partial foot Prostheses is a prosthetic device and I am not 100 percent clear on the number of units allowed. I have not had any issues with Medicare replacing this type of device, but I don’t recall replacing one sooner than a year or two. I also well documented the first one was worn out and not salvageable.
The lcd for therapeutic shoes does not allow,L5000, if the foot loss is a single toe the expectations is t hat the A5513 can be used with a toe filler added. For TMA ‘s the L5000 is used and expected to last, not like the trial inserts.
One toe filler replaces one pair of inserts. One toe filler can be billed for each side, so at best you’re looking at 2 pairs custom inserts and 1 toe filler per side per year.
No source but it’s one.
I was told in the past that this was a prosthesis and would follow the 5 year replacement cycle. I did not agree with it then but there was never any discussion allowed about it.
Not too difficult of a question. Medicare says that you can provide 1 partial foot, then 2 additional inserts for the partial foot portion to be glued or attached after the 4 months of wearing. Being that they are provided 3 pairs of inserts, I have had them change inserts every 4 months and bring them into the office to also examine their feet. At that time, I change the partial foot insert out to a new one. So for your coding, 3 inserts for the sound side, 1 partial foot insert with toe filler, 2 inserts for amputated side to be used at 4 month intervals.
I’m surprised you’re considering using L5000. I think you’d be amazed at the outcomes of using an L5020 device.
See attached PowerPoint PDF that covers shearing forces and acquired LLD secondary to partial foot amputation.
Please feel free to contact me if you have any questions.
You’re right in that the materials are made to contour to the person’s foot just like other custom/diabetic inserts, so why aren’t pts given three? I’ve only ever done one officially, but have provided two custom insert/fillers that are used over a non-attached carbon foot plate. When I first started making them in house, I would just have the pt back at about the 6mo mark & resurface their inserts. I have found that it’s just easier to make two right form the start & have the pt “alternate wear” the two. (We all know that alternating does not happen, but they ill change inserts at the 6mo period.)
If you find something in writing that allows provision of three, please share!
It falls under medicare prosthetic policy- so it can be replaced just as a prosthesis can. I believe that L5000 needs to be more than just a toe filler. If you are just providing a toe filler insert that should probably be billed as as an insert not a prosthesis. Thats what our office follows.