"How to properly bill for diabetic shoes (CPT A5500-A5514)? What modifiers should be used?"
Because there are different types of shoes and different types of inserts, there is not enough information here to thoroughly answer this question. Here is some information to get you started:
As an NYSPMA and APMA member, you have access to excellent guidance regarding participation in the Medicare "Therapeutic Shoes for Persons With Diabetes" program. This guidance was developed in conjunction with PICA and is available to members here:
What follows is not an all-inclusive list of all coding options for this program. Again, there are different shoe types and different insert types with different coding options for each. Here are commonly used codes:
When two shoes are dispensed that meet the definition of code descriptor of HCPCS A5500, and all documentation requirements are met, then 2 units of A5500 may be submitted:
A5500 - For diabetics only, fitting (including follow up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe
When 3 pair of inserts are dispensed that were custom molded from a model of the patient's foot and
meet the definition of code descriptor of HCPCS A5513, and all documentation requirements are met, then 6 units of A5513 may be submitted:
A5513 - 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
When 3 pair of inserts are dispensed that were made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient and meet the definition of code descriptor of HCPCS A5514, and all documentation requirements are met, then 6 units of A5514 may be submitted:
A5514 -For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, 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
When all documentation requirements are met and the rigorous coverage guidelines for this service are all satisfied, the KX Modifier should be appended to both the shoe code and the inserts code.
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC