As a result of its investigation into diabetic inserts, Medicare is establishing
new HCPCS Codes and Medical Policy. The new codes confirm the requirement
to provide the patient with a total contact device. Most of the prefabricated
inserts presently being billed to Medicare will no longer qualify for reimbursement.
In addition, recent legislation will effect reimbursement amounts for diabetic
footwear. This legislation was aimed at reducing reimbursement for prefabricated
inserts. Reimbursement for custom fabricated inserts is expected to remain at the
present level or increase.
New Codes and Policy
Medicare is establishing new codes and medical policy to bring diabetic insert
devices and fabrication technique into compliance with present policy.
Inserts must be molded to the foot or a model of the foot (cast) to achieve total
contact. Total contact means that the shape of the molded device corresponds
to the shape of the plantar surface, including the arch.
New code specifications require both the top and base layer of prefabricated inserts
to be made of heat moldable materials. The materials must be of an adequate
thickness and durometer (firmness) to retain the molded shape and total contact
for the life of the device. Since most of the prefabricated inserts on the market
cannot achieve and maintain Medicare’s definition of total contact, they will not
qualify for reimbursement under the new codes.
In-office molding of prefabricated inserts requires molding the device up to the arch.
The top and bottom of each device must be heated to 230 degrees. The accepted
technique for direct molding is to place each heated insert on a foam molding block.
The device is then molded up to the patient’s arch until cooled.
Custom fabricated inserts must have sufficient arch fill to achieve total contact.
Prefabricated inserts molded to a cast of the foot do not qualify as a custom
fabricated device. The new Medicare Codes and Policies will become effective
on: July 1, 2004.
Medicare Investigation
The investigation focused on the inability of many of the current devices and
fabrication techniques to meet Medicare Policy.
The following problem areas were identified:
Prefabricated Insert Material – Many of the prefabricated devices
on the market have a polyurethane base which is not heat moldable. While many
vendors claim the device is heat moldable, in fact, only the top cover can change shape.
Therefore, the base layer of the device cannot achieve total contact because it is
incapable of forming to the plantar surface, including the arch. Several prefabricated
inserts on the market are totally heat moldable. However, the base layer of the device
is not of a sufficient thickness and durometer to retain the molded shape during
ambulation. These devices cannot retain the shape of the plantar surface for the
life of the device.
Direct Molding Fabrication – Many practitioners are not using accepted
molding techniques to properly capture the shape of the foot. They are heating the
device, placing them in the shoe and having the patient stand on them.
The resulting shape is the same as compression molding which does not
adequately capture the shape of the plantar surface to achieve total contact.
Reimbursement Changes
Congress recently passed the Prescription Drug & Modernization Act
of 2003 (HR1), which will have a significant impact on the reimbursement
of therapeutic footwear. Congressman Mark Foley, introduced Section 626
of the bill as a means of reducing reimbursement for prefabricated inserts.
Presently, the reimbursement limits for diabetic shoes and inserts are
established by Congress within the original Therapeutic Shoe Bill (TSB).
The TSB mandates a single maximum allowable amount for all diabetic
inserts. In 2002, Medicare recognized two different levels of service for
diabetic inserts by establishing separate coding for prefabricated
inserts (A5509) and custom fabricated inserts (A5511). Due to the single
mandated price in the TSB, Medicare was required to reimburse both
codes at the same amount. An Act of Congress was required
to change this policy.
The new law removes the mandated pricing and transfers the authority
to establish payment amounts to Medicare. All TSB items will now become
fee schedule items in the orthotic benefit category. Medicare is required
to establish a separate fee schedule amount for each type of diabetic
insert by January 1, 2005. The new payment amounts will be calculated
according to the orthotic and prosthetic payment methodologies.
Several methodologies can be used to compute fee schedule amounts.
Average retail pricing is the method most likely to be used for diabetic
inserts. For example, in the case of diabetic inserts, a national survey
could be conducted to ascertain average retail pricing for both
prefabricated and custom fabricated accommodative diabetic inserts.
These averages would be used to set a fee schedule amount for
prefabricated inserts (A5509) and another for custom
fabricated inserts (A5511).
PREPARE YOUR PRACTICE FOR THE MAJOR
CHANGES EFFECTING DIABETIC FOOTWEAR.
SureFit’s custom fabricated inserts have always been 100% compliant with the
new HCPCS Codes. With a lab fabricated insert there is no need for
in-office fabrication. The inserts arrive at your office ready for dispensing
FOR MORE INFORMATION CALL A SUREFIT SPECIALIST AT
800-298-6050
