On February 1, 2018 the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a correct coding bulletin that addresses proper coding of diabetic shoe inserts described by HCPCS codes A5512, A5513, and the recently created K0903 which describes custom fabricated, total contact inserts that are manufactured through a direct milling process that utilizes a digital model of the patient’s foot to direct a CAM based system in the fabrication of the insert.
The correct coding bulletin indicates that the PDAC coding redetermination review project, which was initially announced in August of 2017 and scheduled to be completed by June 1, 2018 has been extended to a new completion date of August 1, 2018 to allow manufacturers and central fabricators additional time to submit applications for their respective products. All diabetic inserts billed to Medicare using A5513 or K0903 must be listed on the PDAC product classification list no later than August 1, 2018. Inserts that are not included on the PDAC list by August 1, 2018 must be coded as A9270 and will be considered non-covered by Medicare.
Direct milled inserts described by K0903 must be billed using K0903 for dates of service on or after April 1, 2018, the effective date of the code regardless of how they are currently listed on the PDAC product classification list. In addition, manufacturers and central fabricators of direct milled inserts must submit their product(s) to PDAC for review no later than April 1, 2018.
While K0903 is effective for date of service on or after April 1, 2018, the Centers for Medicare and Medicaid Services (CMS) has not yet issued the Medicare fee schedule amount for K0903. As AOPA previously reported, the FAQ document that accompanied the announcement of the proposed changes to the DMEPOS quality standards that included direct milled, custom fabricated diabetic inserts in the definition of “molded to patient model” included a proposed 14% reduction in the Medicare fee schedule for direct milled inserts. AOPA has challenged this proposal based on several bases, including provisions within CMS’ own instructions to contractors that require the direct crosswalk of established Medicare fee amounts when a single code is exploded into two or more similar codes, and final decision on the fee schedule amount is still pending within CMS leadership. AOPA believes that this instruction applies to the creation of K0903 as it is similar to existing code A5513. AOPA will continue to monitor CMS resources for information regarding the Medicare fee schedule for K0903 and will communicate any new information to AOPA members as soon as possible.
Questions regarding this issue may be directed to Joe McTernan at firstname.lastname@example.org or Devon Bernard at email@example.com.