I was referred a Medicare patient with chronic dfu to make custom inserts (A5513) He recently received shoes and prefab inserts from a vendor this calendar year.
Am I allowed to make ( and get paid for) a pair of the custom insert (A5513) without dispensing the shoes and especially since he has gotten 3 pairs of the A5512
Ron Werter DPM
This is an excellent question and one I both faced clincially when I was in practice and continues to be problematic for both the supplier and patient.
First off, if a patient has already received shoes and three pairs of inserts, no matter which code, then they have exhaused their Medicare coverage.
If the patient has a clinical need for custom inserts then they need to be informed that Medicare will not cover these devices simply because the Medicare policy only permits them to receive three pairs of inserts, regardless of their clinical needs.
As for which device to chose and resolve, you have two choices, again both of which will be the financial burden for the patient and you should have a frank discussion with them about the advantages/disadvantages to both:
If you choose to go the custom molded route (A5513) or custom milled route (A5514), the patient shoud receive three of those. The patient should sign an ABN and if they wish the claim to be submitted to Medicare, then submit the claim with the GA modifier for the LT and RT. Each claim line billed with 3 units.
This will signifify a rejection to Medicare for not medically necessary (according tot their policy) and result a patient responsibility (PR) rejection.
To determine whether your vendor is providing an A5513 or A5514, I suggest you contact them.
Your othe choice and my preference is to make the patient a high quality accomodiative foot orthotic, consistent with L3000-L3020 which will last a few years. This choice would also not be covered by Medicare and the claim would be submitted with a GY modifier (not covered by Medicare) and again generate a patient responsibility (PR) remark code.
In both of the above scenarios if the patient has a private (not Medicaid) secondary insurance, they may (or may not) pick up the charges and pay.
Additionally, if a patient has a pair of shoes which already meet the therapeutic shoe policy, then coverage for the inserts is not predicated on providing them with a shoe at the same time or ever. But that is an extra bonus of information you can tuck away for future reference.
In this case, the patient has already exhausted any and all benefits for the current calendar year.
Good luck and let us know which route you and your patient chose.