AOPA Secures an Advocacy Victory on Reimbursement for Custom Fabricated, Direct Milled Diabetic Inserts


AOPA is very pleased to announce an advocacy win regarding the fee structure for K0903/A5513. AOPA has confirmed with the Centers for Medicare and Medicaid Services (CMS) that the Medicare fee schedule for K0903, a temporary HCPCS code, effective April 1, 2018, that describes custom fabricated, direct milled diabetic inserts has been set at the same amount as the current Medicare fee schedule for A5513 ($43.56 for most states), which describes custom fabricated diabetic inserts that are fabricated over a positive model of the patient’s foot. This has been a very long battle, one in which AOPA partnered with the American Podiatric Medical Association, the O&P Alliance, and the Amputee Coalition.  This is VERY important because A5513 is not the only code where scanning processes have evolved – this hopefully sets the right precedent for the agency.

This battle included a decision, first highlighted by PDAC, that diabetic shoes inserts that were fabricated using scanning devices and direct milling did not meet the precise words of the A5513 code, which referenced the process as molded over a model of the patient’s foot. A coding verification notification was initiated by PDAC to focus on the process used. It should be noted that this code, vital to protecting diabetic patients, had declined in utilization by 14% in the prior 3 years, largely because of unreasonable reimbursement cuts. At an Open Door Forum, CMS announced that they agreed that the processes were equivalent, but also said that the scanned device required less work, and they expected to reduce the fee by about $7 for direct milled inserts. A long battle has ensued, where as a result of Congressional pressure, the fee decision was shifted to the very highest levels in CMS. Ultimately, CMS reached the right decision that as the processes were essentially equivalent, the fee needed to also be identical (one of the several arguments AOPA mounted was the CMS’ own manuals say that when one code is “exploded” into two parallel codes both new codes must retain the same fee), as provided in CMS’ own Medicare Claims Processing Manual

AOPA is proud of this advocacy victory, not only for what it represents for providers of diabetic inserts, but also for the precedent that it sets for future issues involving the use of scanning and other technology to create alternate manufacturing processes in orthotics and prosthetics. AOPA is greatly indebted to Rep. Brad Wenstrup and his excellent staffers – Derek Harley, Nick Uehlecke (Ways & Means Committee) and Greg Brooks for their help, as well as Joe McTernan, Devon Bernard, Ashlie White and others on AOPA’s lobbying team. Believe it or not, this battle started in August, 2017, when we set our strategy, began outreach to podiatrists, and to key Hill players!

Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.orgor Devon Bernard at dbernard@aopanet.org.