AOPA and APMA Send Letter to CMS Administrator Regarding A5513 Coding


On Friday, September 29, 2017 AOPA and the American Podiatric Medical Association (APMA) sent a joint letter to CMS Administrator Seema Verma expressing their concern about the recent DME MAC coding clarification for HCPCS code A5513.

The coding clarification essentially states that in order to bill Medicare for a custom fabricated diabetic insert using HCPCS code A5513, a physical model of the patient’s foot must be created and that the insert must then be molded over the physical model of the foot.  The clarification further states that processes that use a “virtual” model to create a custom fabricated diabetic insert through direct milling or another manufacturing process do not meet the code language for A5513 and therefore must be billed using A9270 which is a HCPCS code used to describe statutorily non-covered services.

The AOPA/APMA letter expresses the concern that the overly strict interpretation of the descriptor language for A5513 limits the use of advanced technologies such as direct milling and 3-D printing to produce diabetic inserts that may result in a more intimate fit for the patient, possibly leading to better outcomes.  The letter also states that the relatively small annual Medicare expenditure for custom diabetic inserts when compared to the overall Medicare expenditure for the treatment of diabetes mellitus is so minimal, that it seems unlikely that “splitting hairs” over such a minor issue will result in any real savings to the Medicare program but will have a negative impact on patient outcomes.

The joint letter suggests that CMS can solve the issue by either instructing the DME MACs and PDAC to be less restrictive in their interpretation of the code language for A5513 or by asking the CMS HCPCS panel to consider a verbiage change that would allow providers to bill custom diabetic inserts as A5513 without the requirement that the inserts be molded to a physical model of the patient’s foot.

Read the AOPA/APMA joint letter.