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Vera Posted Wed 26th of June, 2013 21:19:42 PM

After the proper paperwork has been completed and it is time to mold the patient for DM shoes, - is that a billable visit? Or is the molding of the shoes included in the reimbursment? I have read everything there is out there and it is still not clear to me if that is a billable visit, when they just come to be molded for shoes?

SuperCoder Answered Thu 27th of June, 2013 01:06:39 AM

Codes A5500 (For diabetics only, fitting [including follow-up], custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert[s], per shoe) and 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) correctly apply to footwear prescribed for diabetic Medicare patients. Codes for diabetic shoes have very different descriptions, however, so you should check the specifications of the shoes to make sure that they match codes you report.

Check this out: You'll use A5500 for an adjustable depth shoe that:

• has a full length, heel-to-toe filler that when removed provides a minimum of 3/16" of additional depth used to accommodate custom-molded or customized inserts

• is made from leather or other suitable material of equal quality

• has some form of shoe closure, such as laces or Velcro I

• is available in full and half sizes with a minimum of three widths to assure a proper fit.

For example: Advance Orthopedic and Comfort Footwear qualifies for reimbursement under this definition.

Take note: A5513 is for shoes with the following specifications:

• for diabetics only

• has multiple density insert that is custom molded from model of patient's foot and has total contact with patient's foot, including archbase layer minimum of 3/16" material of Shore A 35 durometer or higher,

• includes arch filler and other shaping material

• is custom fabricated.

There are several more codes specifically for therapeutic footwear suitable for diabetics, with varying specifications, so you should thoroughly read all the code descriptors before choosing a code.

Coding the situation you describe can be tricky because the rules for diabetic shoes change from carrier to carrier. For example in the state of Virginia, you should consult CIGNA Government Services, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C, which includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia.


Medicare provides limited coverage, based on established medical necessity requirements:

One pair of custom-molded shoes (including inserts), if the beneficiary cannot wear depthinlay shoes because of a foot deformity, and two additional pairs of inserts within the calendar year;

Vera Posted Thu 27th of June, 2013 17:43:48 PM

This information does not answer my question. We are jurisdiction F - (formerly D) - and I do not find any information about billing or not billing, an office visit where the patient is molded for shoes, only. All the extra information you supplied, looks like it's from the LCD's - which I can find myself, and have read many times. The question was simple - but apparently very complex to get an answer. >:(

SuperCoder Answered Fri 28th of June, 2013 20:57:09 PM

Your frustration with this question is understandable because it’s difficult to find something that says straight out ‘all visits related are included in the HCPCS code.’ There’s also the rule about an in-person visit that includes getting impressions, casts, or CAD-CAM images for A5501 and A5513.

Because you’ve read the LCDs and articles, you’ve likely seen lines like: “There is no separate payment for the fitting of the shoes, inserts or modifications or for the certification of need or prescription of the footwear” ( Codes like A5501 also include fitting and custom preparation in the definition.

That leaves the question of whether fitting, prescription, custom preparation, etc., include the mold visit. The long listing of what’s included suggests related services are included in the HCPCS code for fitting, prep, and supply of the shoe. Everyone agreed molding, scans, etc., are included in the code, although there are no links to authoritative sources, in the discussion here about insoles: If something more authoritative comes up in research, expect to see an update posted!

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