RETIRED - Correct Coding - A5513 Custom Molding Requirements - JA DME

This article is retired effective February 1, 2018. Current direction on correct coding as well as revised information about the Coding Verification Review project process are included in the article titled: Correct Coding – Inserts Used with Therapeutic Shoes for Persons with Diabetes (A5512, A5513, K0903), published February 1, 2018.

DME MAC Joint Publication

Posted on July 13, 2017

Medicare provides coverage for therapeutic shoes and related inserts for beneficiaries with diabetes. Custom molded inserts are billed using HCPCS code A5513 [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]. Inserts billed with A5513 must be made in compliance with criteria specified in the code narrative described above, the coding guidelines section of the LCD related Policy Article, and the DMEPOS Quality Standards. Suppliers of these inserts must assure themselves that the products provided meet the requirements for classification as A5513 before billing this HCPCS code. 

The HCPCS code narrative passage, "…CUSTOM MOLDED FROM MODEL OF PATIENT'S FOOT…", requires that a physical model of the beneficiary's foot must be produced and that the insert be individually molded to the physical model.  Some manufacturers do not produce an actual physical model of the individual beneficiary's foot.  Instead, a CAD-CAM system creates an electronic positive model derived from specific patient measurements, i.e. a "virtual model", or use a library of generic models to fabricate an insert.  Inserts produced using these or similar techniques must not be coded as A5513 for Medicare billing.

The Medicare Benefit Policy Manual (Internet Only Manual 100-2) chapter 15, §140 describes the benefit requirements associated with therapeutic shoes.  It describes a covered insert.  The section says, in relevant part:

• 3. Inserts - Inserts are total contact, multiple density, removable inlays that are directly molded to the patient's foot or a model of the patient's foot and that are made of a suitable material with regard to the patient's condition. [Emphasis added]

The Therapeutic Shoes for Persons with Diabetes LCD related Policy Article coding guidelines section says:

• Code A5513 describes a total contact, custom fabricated, multiple density, removable inlay that is molded to a model of the beneficiary's foot so that it conforms to the plantar surface and makes total contact with the foot, including the arch. A custom fabricated device is made from materials that do not have predefined trim lines for heel cup height, arch height and length, or toe shape. [Emphasis added]

The DMEPOS Quality Standards Appendix C (42 CFR 424.57) defines custom fabrication for these items and requires that custom fabricated inserts be made to a physical model of the individual beneficiary's foot.  Appendix C says, in relevant part:

1. Custom Fabricated: A custom fabricated item is one that is individually made for a specific Patient. No other patient would be able to use this item…

• Molded-to-Patient-Model: A particular type of custom fabricated device in which either:
  • An impression (usually by means of a plaster or fiberglass cast) of the specific body part is made directly on the patient, and this impression is then used to make a positive model of the body part from which the final product is crafted; or
  • A digital image of the patient's body part is made using Computer-Aided Design-Computer-Aided Manufacturing (CAD-CAM) software. This technology includes specialized probes/digitizers and scanners that create a computerized positive model, and then direct milling equipment to carve a positive model. The device is then individually fabricated and molded over the positive model of the patient. [Emphasis added]

These standards are not met by:

• Electronic (virtual) beneficiary models created within CAD-CAM systems which in turn are used to directly fabricate the insert; or,
• Generic models which are used to create a nonspecific insert for later modification to individual beneficiary specifications.

Therapeutic shoe inserts produced from virtual or generic models must be billed to Medicare using HCPCS code A9270 [NON-COVERED ITEM OR SERVICE].

Refer to the Therapeutic Shoes for Persons with Diabetes LCD and related Policy Article for additional information about coverage, coding, and documentation.

For questions about correct coding, contact the Pricing, Data Analysis, and Coding (PDAC) contractor at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form at https://www.dmepdac.com/.