PDAC Announces a Coding Redetermination Project for Custom Diabetic Inserts (A5513)

On July 13, 2017, the DME MACs published a joint publication that addressed the proper use of HCPCS code A5513, which is used to described molded to patient model diabetic shoe inserts.

The joint publication indicated that in order to meet the requirements of the HCPCS code descriptor, diabetic inserts billed using A5513 must be molded over an actual model of the patient’s foot.  The publication further clarified that the use of generic, electronic or “virtual” models where custom fabrication occurs without creation of a physical model of the patient’s foot does not meet the code descriptor, and diabetic inserts fabricated this way cannot be billed as A5513.

On August 10, 2017, the Pricing, Data Analysis, and Coding Contractor (PDAC) announced that based on the previously published coding clarification, it would initiate a Coding Redetermination Project for diabetic inserts described by A5513.  As part of this project, all previous A5513 PDAC coding verifications will be end dated effective May 31, 2018.  Manufacturers and central fabrication facilities who wish to have their products PDAC verified for A5513 will need to submit a new application to the PDAC.  This applies to both new products as well as existing products that were previously verified by the PDAC.  The PDAC has indicated that applications should be submitted well in advance of the May 31, 2018 end date in order to allow adequate time for the PDAC to complete its review.

The PDAC notice stated that products that are currently PDAC verified for A5513 may continue to be billed using A5513 until the May 31, 2018 end date.  Medicare claims for diabetic inserts described by A5513 with a date of service on or after June 1, 2018 will require a new PDAC coding verification using the requirements outlined in the July 13, 2017 coding clarification.

As a reminder, AOPA members who are fabricating diabetic inserts described by A5513 for use by their own patients are not required to obtain PDAC verification but must meet the requirements of the code descriptor which includes the creation of a positive model of the patient’s foot. View the complete PDAC announcement.

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