02/18/2022

1199-Billing for DME Shoes and Custom Inserts

1199 allows for DM shoes, A5500, but not for the current code for custom inserts, A5514, from CAD/CAM. They still allow for the old code A5513. Should we use A5513?

The HCPCS code billed to 1199 depends on the method that is used to cast the mold on the patient’s foot for the inserts that are applied, and that should be the basis of the code billed on the claim. HCPCS A5513 should be billed when inserts are created using a positive model of the patient’s foot by pouring plaster not a foam impression or carving a foam or wood model, with no use of technology. HCPCS code A5514, while it may have a physical impression or slipper cast, is used by using CAD-CAM and uploaded to the manufacturer of the inserts to create a model that will be inserted into the diabetic shoes. The choice of the coding must be substantiated by the documentation in the patient chart and the method of creating the inserts.