Retired - Submitting Diabetic Shoe Inserts for Coding

Diabetic inserts coded as A5512 and A5513 must meet the material thickness and Shore A durometer scale hardness measurements outlined in the Local Coverage Determination and Policy Articles for Therapeutic Shoes for Persons with Diabetes.

For inserts to be coded as A5512, the product must be a heat moldable “base layer” with a material thickness of at least ¼ of an inch of 35 Shore A or higher or at least 3/16 of an inch of 40 Shore A or higher, be coded by the Pricing, Data Analysis and Coding (PDAC), and be listed on the Product Classification List. A sample pair of inserts must be submitted with the Coding Verification Application. Applications are available on the PDAC website at www.dmepdac.com.

For inserts to be coded as A5513, the product must retain its shape during use for the life of the insert. The base layer material must be 35 Shore A or higher. The central portion of the base layer of the heel must be at least 1/16 of an inch on the finished product, be coded by the PDAC, and be listed on the Product Classification List. Manufacturers/central fabrication facilities must submit a 4 x 4 x ½ inch sample of base layer material(s), a sample pair of inserts, a narrative description and pictures of the manufacturing process, and a completed Coding Verification Application. Applications are available on the PDAC website at www.dmepdac.com. A copy of the original Coding Verification Letter to the manufacturer / central fabrication facility, approving the product as A5513, must be kept on file and available to distributors, suppliers, and CMS contractors upon request.

Practitioners who create custom fabricated inserts from raw materials for dispensing directly to the end user (the beneficiary) are not required to have their insert listed on the PDAC website in order to bill using code A5513. However, a coding verification request may be submitted to the PDAC to ensure accuracy of the code for the item provided. If a Coding Verification Review is requested, a 4 x 4 x ½ inch sample of base layer material(s), a sample pair of inserts, a narrative description and pictures of the manufacturing process, and a completed Coding Verification Application must be submitted.

Coding verification results are subject to review and observation by CMS and its contractors, including the PDAC, DME MAC, Program Safeguard Contractor (PSC), and Zone Program Integrity Contractor (ZPIC).

Suppliers are reminded to access the PDACs Durable Medical Equipment Coding System (DMECS) https://www4.palmettogba.com/pdac_dmecs/ for any questions regarding the correct coding of products or call the PDAC Contact Center at 877-735-1326 between the hours of 8:30 a.m and 4:00 p.m. CT.

Please note that links in this document were accurate at the time of original publication and may change over time and are no longer active.