Thank you everybody for getting back to me regarding this question. Some
people responded that a transmet amputation is necessary in order to use
L5000 and others felt that under certrain circumstances L5000 could be used
for hallux amputations. For a clear description of L5000 vs A5513 I
suggest looking at the website that Billing Coordinator Mr. Cesar Fernandez
From what I have learned from the responses I personally feel most
comfortable basing the LCode on the biomechanical requirements of a
patient. If I feel that a patient needs me to biomechanically supplement
their gait with the insert by, say, helping with balance or giving a bit
more “kick” to their toe off then I would feel comfortable going with L5000
as long as I had appropriate documentation to back up my approach.
However, if I was merely going for cosmesis or even wound prevention with
the toe filler such as preventing the foot from moving around in the shoe
then I would feel more comfortable with A5513. My patient in particular
has bilateral foot drop in conjunction with his diabetic toe amputations
and he has weak plantar flexors as well. I therefore plan to use A5513 for
his inserts and to supplement his toe off with an L1932 carbon AFO. I have
posted the responses below and if anyone would like to get in touch with a
respondent the please let me know and I will be happy to try to make the
connection. Thank you all again.
Yitzchak Langer, CPO
Presque Isle Medical Technologies
1)That answer depends on the payor. Medicare has clarified L5000 to be
2) This link has helpful hints in regards to coding of toe fillers. It’s
pretty specific and I hope will help you come to a conclusion about how to
3) If it is a Medicare patient they must have a transmet amputation to us
L5000. If not use the A5513.
4) L5000 is appropriate for great toe amputation.
5) I don’t believe that Medicare policy specifically addresses this, but
given that toe amputations (895.0 and 895.1) and partial foot amputations
(896.0-3) have different diagnosis codes, I have always assumed for the
sake of comfort that I cannot use L5000 for a single toe amputation.
However, when I have had patients with multiple toe amputations, or all of
the toes amputated, and for reasons of medical necessity the device is
nearly identical to what I would use for a TMA, I will use the L5000 code
with a -52 modifier and a lower fee.
One functional difference between the two is that the toe amputee can still
load their metatarsal heads, whereas a TMA cannot, thus requiring more care
and shaping of the mold. For many single toe amputees I do not find the
functional need for any kind of filler, so there would be a problem with
using L5000 under those circumstances anyway.
Given that your patient is diabetic, I would normally use A5513 under these
6) The L5000 code can be used to bill for toe fillers for hallux
amputations, just make sure your documentation is in order.
7) I have read that the lesser toes do not qualify for L5000, but the
hallux do, as their loss is functionally significant. You must add a carbon
plate or other stiffener.
8) It’s been discussed here before. He is no L5000. You must have transmet
9) Sometimes the level is not the key. More that if they need it. Does your
notes explain why it’s a benefit. A5513 is a given for a code. L5000 works
great when the can use it.
10) I do not think there is any document that states this but from what i
am told the use is not based off of level of foot amputation, only bio
mechanical medical necessity/need. Medically justifying the toe filler.
11) I am not sure about L code requirements in this regard but in my own
clinical experience I am reluctant to include any sort of filler for just a
toe amptutation-even the great toe. As long as the 1st met heads are intact
I do not incorporate any filler as this is seldom needed and often causes
pressure problems especially with neuropathic lack of protective sensation.
With this in mind and sticking with the “code what you design and fit”
guidelines I would use A5513.