On December 11, 2017, AOPA submitted formal comments on CMS’ proposed change to the DMEPOS Quality Standards that would expand the definition of the term “molded to patient model” to include custom fabricated diabetic inserts that are fabricated using a virtual or digital model of the patient’s foot and a direct milling process. Earlier this year, the DME MACs published a correct coding bulletin that indicated that because direct milled inserts were not molded over a positive model of the patient’s foot, they could not be billed using HCPCS code A5513 and would have to be billed using A9270 which is a statutorily non-covered service.
The proposed change to the DMEPOS Quality Standards creates a pathway for Medicare coverage for direct milled inserts but a subsequent frequently asked questions (FAQ) document published by CMS indicates that direct milled inserts cannot be billed using A5513 and that reimbursement for inserts fabricated this way will be reduced by approximately 14%.
AOPA’s comments generally supported the proposed change to the DMEPOS Quality Standards but challenged the CMS proposal to arbitrarily reduce the reimbursement rate for direct milled inserts. AOPA believes that the manner of fabrication is irrelevant and that the proposed change to the DMEPOS Quality Standards should allow direct milled inserts to be properly billed using A5513.