Partial Foot, Shoe Insert (Toe Fillers), and Shoe Inserts for Diabetics - Coding Based on Benefit Category - Correct Coding - JA DME

Joint DME MAC Publication
Posted December 16, 2021

Questions have arisen about the correct coding of devices used by beneficiaries who need accommodation for missing digits (toes). Correct coding is determined by which benefit category is used for reimbursement. Beneficiaries who are diabetic and receive therapeutic footwear and shoe inserts for the protective function related the management of the individual's diabetes, would be coded utilizing HCPCS codes such as A5512, A5513, or A5514. However, beneficiaries with or without diabetes that require standing balance and toe off support to accommodate the missing digits (toes), would receive devices related to the prosthetic benefit which are coded with L-code(s) such as L5000, L5010, and L5020. HCPCS codes are related to the Medicare benefit category and the use of codes from another benefit category is incorrect coding.

Partial Foot and Toe Filler Inserts for Standing Balance and Toe Off Support to Accommodate the Missing Digits (Toes)

L5000 (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, L5000 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.

L5010 (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. L5010 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, L5010 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.

L5020 (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. L5020 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, L5020 devices are designed to provide standing balance and toe off support for improved gait. All closures are included, any type. L5020 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.

Shoe Inserts for The Protective Function Related the Management of The Individual's Diabetes

A5512 (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)

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)

A5514 (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)

Coding Options for Persons with Diabetes

For a beneficiary with diabetes and missing digit(s) or a forefoot, suppliers have two options for billing inserts/devices:

Option 1: For diabetic beneficiaries who do not require the rigidity and support afforded by code L5000 (e.g., beneficiaries missing digits excluding the hallux), suppliers must bill code A5513 or A5514 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 L5000, 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 A5512, A5513, or A5514 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.

Suppliers are encouraged 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.

Correct coding is an essential element for correct claim payment. The Pricing, Data Analysis and Coding (PDAC) contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the Pricing, Data Analysis and Coding (PDAC) HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm ET, Monday through Friday. You may also visit the PDAC website to chat with a representative, or select the Contact Us button at the top of the PDAC website for email, FAX, or postal mail information.

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