INDUSTRYNEWS
CMS Launches Redetermination Project Regarding A5513 Process
In the DME MAC Joint Publication article [ 1 ] ( figure 1 - click here ) they have laid out the following language in the Medicare Policy Manual and the associated Local Coverage Determination ( LCD ):
The Medicare Benefit Policy Manual ( Internet Only Manual 100-2 ) chapter 15 , § 140 describes the benefit requirements associated with therapeutic shoes . It describes a covered insert . The section says , in relevant part :
3 . Inserts
Inserts are total contact , multiple density , removable inlays that are directly molded to the patient ’ s foot or a model of the patient ’ s foot and that are made of a suitable material with regard to the patient ’ s condition .[ Emphasis added ]
The Therapeutic Shoes for Persons with Diabetes LCD related Policy Article coding guidelines section says :
Code A5513 describes a total contact , custom fabricated , multiple density , removable inlay that is molded to a model of the beneficiary ’ s foot so that it conforms to the plantar surface and makes total contact with the foot , including the arch . A custom fabricated device is made from materials that do not have predefined trim lines for heel cup height , arch height and length , or toe shape .[ Emphasis added ]
This can be distilled down to say that A5513 describes an insert that is either molded directly to the patient ’ s foot or to a model of the patient ’ s foot . CMS then goes on to quote the DMEPOS Quality Standards :
The DMEPOS Quality Standards Appendix C ( 42 CFR 424.57 ) defines custom fabrication for these items and requires that custom fabricated inserts be made to a physical model of the individual beneficiary ’ s foot . Appendix C says , in its relevant part :
Figure 1 : CGS Website - DME MAC Joint Publication Article
50 Pedorthic Footcare Association www . pedorthics . org