Part I of this series on therapeutic shoe insert coverage, discussed the “Same and Similar” issues of providing inserts and in the second we discussed providing inserts as a standalone benefit. In this third of a series, we will discuss how to handle another frequent scenario. A patient has already received heat molded inserts (A5512) and due to a progression of pathology, now in the same calendar year, requires a custom device (e.g. A5514)
This all too familiar issue happens most often when another provider does not provide custom inserts (A5513 or A5514) and only the heat molded inserts (A5512). The patient is dissatisfied and/or they are referred by another physician for follow-up because of clinical failure and progressive symptoms.
After determining that the off-the-shelf, heat molded inserts won’t adequately address the patient’s condition, first check the Medicare portals. Is it possible for the patient to have received their current inserts in a different and previous calendar year? If that is the case, simply bill for custom milled inserts, A5514 upon dispensing. If, however, that is ruled out and the patient has received the inserts in this present calendar year, then unfortunately, they have reached both the frequency limit and met head on with the Same and Similar issues discussed in Part 1 of this series. So, what can one do?
This dilemma is not really a coding but a practice management issue. Does the patient need a custom insert or do they really require a custom accommodative or custom functional/accommodative hybrid device. The custom insert will not be covered this calendar year but may be the following year. The custom orthotic will likely never be covered by Medicare, unless placed into a shoe attached to a brace.
Having an open and honest discussion about the merits and disadvantages of custom inserts vs. custom orthotics is a must. The patient should hear both the clinical and financial issues for both devices and then decide on which route to take. Your guidance on clinical issues is of course paramount, but some patients may not be able to afford a custom orthotic device. Depending on the time of the year, there is no mandate that you provide them with 3 custom milled (A5514) devices. But bear in mind that there is a minimum set up fee for fabricating the inserts and this will affect the pricing of the device.
Part IV of this series will provide some clinical examples and alternative pathways for your practice to follow for this scenario.
