Coding Structure Inserts - Medicare instituted a coding structure for diabetic inserts as of April 1, 2004. Coverage is determined by the fabrication method and the achievement of total contact. The service documentation required would depend on the level of service provided (A5510, A5512 and A5513).
A5510 - For diabetics only, direct formed, compression molded to patient's foot without external heatsource, multiple-density insert(s), prefabricated, per shoe. **Placing a prefabricated insert in a patient’s shoe and permitting the heat and pressure of the foot to compression mold the device - NON-COVERED SERVICE**
Documentation: None required, this fabrication technique is a non-covered service and will deny payment.
A5512 - Prefabricated insert molded directly to the foot withexternal heat source. For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact withpatient's foot, including arch, base layer minimum of 1/4 inchmaterial of shore a 35 durometer or 3/16 inch material of shore a 40 (or higher), prefabricated, each.
Documentation: Vendor’s invoice for an insert capable of achieving total contact via external heating and direct molding to the foot. Medical notes documenting the direct molding technique utilized to achieve and verify total contact with the plantar surface of the foot. The practitioner is responsible for documenting the achievement of total contact to qualify for coverage.
A5512 - For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated, each.
Documentation: The orthotic laboratory invoice for a custom molded total contact device.