“I’m trying to determine the coverage of diabetic shoes for a patient who has had one foot/leg amputated. Somewhere in my brain I seem to remember that Medicare will cover a pair of shoes so the amputee can wear the shoe on his prosthetic. Does this also apply to heat moldable inserts? Can we dispense them for the shoe that will be used on the prosthetic leg? I would appreciate any thoughts on this situation. I have read the LCD and associated article but can’t seem to fully understand how this works.”
So, a diabetic patient qualifies for a pair of extra depth, therapeutic shoes. Unfortunately, one of the patient’s feet was amputated. This does not prevent the patient from being fitted for one pair of diabetic shoes. The diabetic shoes are billed using HCPCS Level II code A5500 which is defined as:
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.
The appropriate coding scenario would be the following:
A5500 - RT, KX
A5500 – LT, KX
The KX modifier is used to indicate DOCUMENTATION ON FILE: Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service. This modifier is used on all line items for claims that are submitted to the DMERC.
As far as the heat molded inserts are concerned, this creates a problem. The HCPCS Level II code for the heat molded inserts is A5512. It is defined as the following:
FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1⁄4 INCH MATERIAL OF SHORE A 35 DUROMETER (OR HIGHER), PREFABRICATED, EACH.
The insert needs to be “molded to the patient’s foot” after being appropriately heated and needs to be in “total contact with the patient’s foot.” Obviously, the insert can be heat molded to the patient’s one foot. The other insert cannot be heat molded to the patient’s prosthesis on the distal end of the patient’s other lower extremity. Since a patient can receive 3 heat molded inserts for each foot, the correct coding scenario would be the following:
A5512 – RT or LT, KX x 3 units
This is my opinion.
Michael G. Warshaw
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