November 2017

CMS amends custom diabetic insert coding

The Centers for Medicare and Medicaid Services have amended a recent coding clarification regarding custom-fabricated diabetic shoe inserts, which two specialty organizations had criticized as being unnecessarily strict and a detriment to advanced technology.

According to the original clarification, to bill Medicare for a custom-fabricated diabetic insert using HCPCS code A5513, practitioners would have had to create a physical model of the patient’s foot and then use that mold to fabricate the insert. Any process that used virtual models to create inserts, either through direct milling or other means, would not have met the standard and instead would have had to be billed using the code A9270, which describes statutorily noncovered services.

However, following a joint letter in October from the Alexandria, VA-based American Orthotic and Prosthetic Association (AOPA) and the Bethesda, MD-based American Podiatric Medical Association expressing concern about the clarification, CMS has proposed a change that would allow for the creation of a digital positive model of the patient’s foot using computer-aided design and computer-aided manufacturing (CAD-CAM) technology. Practitioners can then use that model to direct mill a custom-fabricated insert and still meet the A5513 standard, according to an AOPA press release.

Public comments on the proposed changes will be accepted through December 11; send to According to AOPA, CMS intends to finalize the changes by January 1, 2018.

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