Sunday, June 16, 2024

“A” Code Responses

To the List,
First, my apologies–between my browser and the world of Microsoft, the HTML codes &#8212, &#8220, A&#8221 were inserted instead of hyphens in my message–surely an ideal way to confound a coding issue if I ever saw one! (although this did not affect all recipients of my message).
Second, it looks like my HCPCS book (published by the AMA press) is in error when it (quite clearly) designates the three new “A” codes as “Noncovered”. One is left to wonder how much other misinformation is out there. You might want to keep that in mind if one of your physicians (or more likely their MAs or PAs have taken time to peruse the AMA version of
reality) confronts you over what Medicare covers.

Here are the responses to date to my query concerning the replacements for
A5502:

As I read it, the only code that is not covered is
A5510. Since it is pressure molded as it is worn it
does not meet the Medicare standard of being “total
contact” at the time of delivery. The other two codes
are covered. The reimbursement rate stayed the same as
for last years A5502. My reading of the new regs was
validated this past week in a company wide coding
meeting.

Medicare only changed the definitions to better
reflect what the patient gets.

I think you are reading it wrong. Just the one code is no longer covered. Go to www.pedorthics.org to see what the new regulations are.

What are the 8221 codes you are refering to?
The new “A” codes did to our knowledge eliminate the 5502, it was way to abused. The three new codes are 5509 – 11 and one of them which I can’t remember at this time, I thinks it’s 5510 is basicly an insert just stuck in the shoe with no premolding. This one is not going to be covered by “Medicare” according to the AOPA in Advance notice that is. I’m at home, not in the office and using my memory. Let me know if you have other questions.

Where did you get your new 2002 hspc book I beed one and would like to know where I can purchase it….. also am concerned about the insole question and would like to know as well if this is true .

As to your question on the A5509, 5510 and 5511 codes. It goes like this. A5509 and A5510 are for prefabricated multi density diabetic insoles. Under the A5509 code the device must be heated – either with a heat gun or in an oven and pulled over a cast. Since you are dealing with Plastazote which is very accomodative it is probably best to use a heat gun sparingly, and pull over a cast in only the extreme cases. If you do this you will get reimbused under 5509. If you bill under 5510 you will NOT get reimbursed. Even though you can essentially accomplish the same as heating by letting the patient mold the insoles via weight. A5511 is for custom insoles, not prefab.


We have been unsuccessful at collecting from Medicare on the A5509 which should be the prefab FO. The A5511, however, is covered by Medicare for Diabetics provided that they meet the criteria laid out by Medicare. (We almost always do these anyway, I guess it is just because I don’t feel good about fitting off-the-shelf orthotics even if they are first heated in a convection oven.) Medicare has paid us many times already over the past month an a half for this code…Unfortunately, they still only pay about $65.00 per pair. This sucks!!! At this rate, by the time I or one of my Cpeds does an eval, listens to their ENTIRE medical history, fits them with shoes, takes an impression or cast of their foot, makes the mold fabricates the orthoses and sees them again for a fitting of the orthotics, we have definitely lost money. One can rationalize that we will make it back on other devices, but unless we want to turn these people away, or make them pay out-of-pocket like most facilities do, we just have to take it. This is a subject that we have had much discussion about in recent months, and are considering these types of options. I would love to hear what the other responses show. If you don’t post them, please at least forward them to me. Thanks.

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Send me a Fax number and I’ll share a copy of the AOPA in Advance with you. It’s my only resource on this issue at this point.
—-
Harry, my comment on your post goes like this. In our Dmerc region D we were told that A5509, A5510, A5511 are all set at $33.00. However, that is likely to change soon because they are still trying to figure out the whole mess. Codes &#8212, &#8220, A&#8221 are mystery codes to me. With an “x” as the alpha the codes are medcaid codes. I forgot which ones were which but some are not covered.

—-
As a Pedorthist and a member of the PFA (Pedorthic footwear Association) I have learned that the original insert code is still in use until March 2002. The new codes are tricky. The code for prefabricated inserts is NOT covered. The code for heat formed (heatgun etc.) prefabricated inserts are covered. The code for custom molded inserts are covered. The catch is this, the allowables are the same (around $60-65/pair) even for the custom molded inserts. Three pairs/year are still allowed (or two pairs and a modification). PFA is lobbying for Medicare to consider paying more for the custom molded inserts ( a total of approx. $180-190/ pair) but reducing the allowed amount to cover only one pair a year (which doesn’t hurt the government’s budget because the price they are lobbying for is exactly the same per year as three sets of the other inserts). Anyway, I hope this helps with the questions relating to the A- codes. If there are any further questions call PFA

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