CORRECT CODING – A5513 PRODUCT CODING REDETERMINATION PROJECT
Retired and replaced by Noridian as the PDAC, February 2018.
DME MAC Joint Publication
In July 2017, the DME MACs published an article titled Correct Coding – A5513 Custom Molding Requirements DME MAC Joint Publication. The article advised suppliers and manufacturers that the DMEPOS Quality Standards, Appendix C require that custom fabricated inserts (HCPCS Code A5513 - FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT'S FOOT, TOTAL CONTACT WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH) be manufactured on a beneficiary-specific, physical, positive model. Direct carving (milling) using a CAD-CAM or similar system, without the creation of the required physical, positive model does not meet this requirement. Therefore, the PDAC will begin a project to re-evaluate all the products currently listed in DMECS for code A5513 to assure that inserts billed to Medicare with HCPCS code A5513 are correctly coded.
New Coding Verification Review - Required
Per the Coding Guidelines section of the Therapeutic Shoes for Persons with Diabetes LCD-Related Policy Article, manufacturers wishing to use A5513 for their product(s) are required to submit a coding verification application to the PDAC. Therefore, all products must be submitted for this review. There is no carryover or “grandfathering” of prior coding determinations.
All products currently listed in the DMECS Product Classification List on the PDAC web site as assigned to HCPCS code A5513 will be end-dated effective May 31, 2018. After this end-date only products that have completed this current review and that have been verified as meeting all A5513 code requirements will be listed. Effective for claims with dates of service on or after June 1, 2018, the only products which may be billed to Medicare using code A5513 are the products that are listed in the Product Classification List in DMECS maintained on the PDAC website: https://www.dmepdac.com
For claims with dates of service on or before May 31, 2018, products that are presently listed in the Product Classification List in DMECS may continue to use code A5513 for Medicare billing.
Products which have not received coding verification review from the PDAC must be billed to Medicare with code A9270 (NONCOVERED ITEM OR SERVICE).
Coding Verification Review Process
PDAC coding reviews can take up to 90 days to complete. PDAC strongly encourages applicants to submit coding verification applications well in advance of the May 31, 2018 end-date to avoid disruption to the billing of their products. Manufacturers are also encouraged to be sure that coding applications clearly and unambiguously show that all applicable coding requirements are met. The PDAC coding verification application required for these products is the Therapeutic Shoes and Inserts for Diabetics. This application is located on the PDAC website: https://www.dmepdac.com.
Refer to the Therapeutic Shoes for Persons with Diabetes LCD and related Policy Article for additional information about coverage, documentation and HCPCS coding. In addition, the correct coding article published July 13, 2017 by the DME MACs titled, Correct Coding - A5513 Custom Molding Requirements DME MAC Joint Publication, contains a detailed discussion of the need for an actual, physical “positive model” upon which the insert must be fabricated.
For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www.dmepdac.com/.
Published by Noridian as the PDAC, August 2017. Republished by Palmetto GBA as the PDAC January 2019.