Coding project reveals outdated guidelines

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Friday, October 20, 2017

WASHINGTON – A coding redetermination project for custom diabetic inserts could be a sign of the times, where guidelines don’t keep pace with technology.

In August, the Pricing, Data Analysis, and Coding Contractor announced it would initiate the project for A5513 after the DME MACs issued a joint publication stating that, to meet the requirements of that particular code, the insert must be molded over an actual model of the patient’s foot.

Although many models are still made using older methods like plaster casts or crush boxes are still used, scanning technology is being used with increasing frequency to create virtual models.

“As technology has advanced, manufacturers have been making, typically, scans of the foot, feeding them into additional software which is then, in turn, direct milling the insert based on the scans,” said Joe McTernan, director of coding and reimbursement services, education and programming for the American Orthotics and Prosthetics Association. “Because there’s a positive 3-D model created apart from that overall process, the MACs have said this does not meet the code and cannot be billed as such.”

For providers, any insert coded as A5513 can still be billed the same way through May 31, 2018. However, manufacturers will have to submit a new application to the PDAC for both existing and new products under that code.

The MACs are likely acting out of an abundance of caution, say stakeholders.

“They don’t want to get skewered by not strictly adhering to the wording of the code,” said Tom Fise, executive director of AOPA. “I think they are looking for CMS to solve this problem. If they were told to look at the device, and don’t get hung up on one or two words, as long as the end product is the same, that would give them a little leeway they don’t feel they have right now.”

With the number of people in the U.S. with diabetes exploding, costing upward of $250 billion a year, for CMS to say it won’t pay $50 for an insert that could prevent a foot amputation is shortsighted, says Fise.

“If we are more concerned about the casting and being able to touch the model than they are about the quality of outcomes, it’s hard to make advances in terms of quality,” he said.