Proposed changes to insert guidelines draw criticism

Friday, December 1, 2017

WASHINGTON – A proposal to “explode” the code for custom therapeutic inserts has raised eyebrows among stakeholders who say it’s unnecessary.

In a Special Open Door Forum Nov. 28, CMS officials outlined plans to revise the DMEPOS Quality Standards for custom fabricated inserts to account for advances in technology that allow them to be direct milled using computer assisted software. However, because the technology is so different, the inserts must be billed under a new code, rather than under the existing A5513, they agency says.

“We were surprised they created a new code,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “Typically, they just redefine the current code.”

The kicker: The reimbursement under the new code will be $38.67 per unit—a 14% decrease.

“The Medicare reimbursement manual says that when you explode codes, both codes will have the same value,” said Tom Fise, executive director of the American Orthotic and Prosthetic Association. “How does CMS get to magically say they are going to reduce the payment by 14% because you are creating the same product but you are not using the same manufacturing process?”

AAHomecare is seeking clarification on how CMS arrived at the new reimbursement rate, says Brummett.

CMS had already begun looking to update guidelines that haven’t kept pace with technology. In August, the Pricing, Data Analysis, and Coding Contractor announced it would initiate a *coding project for A5513.

The deadline to submit comments on the proposed changes is Dec. 11 and can be done via email at