Therapeutic Shoes for Persons with Diabetes - Policy Article

Revision Effective Date: 12/05/2024
CODING GUIDELINES:
Revised: “If an insert is not included in one of these categories of items (A5512, A5513, A5514), it must be billed with code A5510 or A9270 (noncovered item).” to “If an insert for a diabetic shoe does not meet the coding guidelines of A5512, A5513, or A5514, then the insert must be billed using either HCPCS code A5510 or A9270 (noncovered item).” as clarification
Removed: Coding verification review information for HCPCS codes A5512, A5513, and A5514
CODING VERIFICATION REVIEW:
Added: Section header and PDAC coding verification review information
Added: Coding verification review information for HCPCS codes A5512 and A5513
Added: Coding verification review information for HCPCS code A5514, for claims with dates of service on or after January 1, 2019 through December 4, 2024
Added: Coding verification review information for HCPCS code A5514, for claims with dates of service on or after December 5, 2024
12/05/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 11/05/2020
MODIFIERS:
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
CODING GUIDELINES:
Removed: RT and LT modifier information
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10-CM codes E11.10 and E11.11 to Group 1 Codes (Effective for claims with dates of service on or after October 1, 2017)
05/09/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 11/05/2020
CODING GUIDELINES:
Removed: Reference of HCPCS codes for inserts and modifications used with L-coded footwear
Added: Language referring to the Orthopedic Footwear LCD and LCD-related Policy Article for more information
Added: Language referring to the Lower Limb Prostheses LCD and LCD-related Policy Article for information pertaining to coverage of devices under the prosthetic devices benefit category


07/07/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 11/05/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 11/05/2020
CODING GUIDELINES:
Added: “(PCL)” after reference to “Product Classification List”
Added: Incorrect coding denial language for products billed using HCPCS that require written coding verification review
03/18/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 11/05/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Certifying physician information, to clarify NPs or PAs practicing ‘incident to’ supervising physician
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “detailed written order” to “SWO”
Revised: Certifying physician information, to clarify NPs or PAs practicing ‘incident to’ supervising physician


11/19/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Order information as a result of Final Rule 1713
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
CODING GUIDELINES:
Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS
Revised: HCPCS codes referenced for inserts and modifications, to include A5514
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


03/05/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: HCPCS A5514 to the reference of “inserts” for which impressions, casts, or CAD-CAM images, of the beneficiary’s feet, are to be obtained by the supplier at the time of item selection

09/05/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: References to K0903 crosswalked to A5514
CODING GUIDELINES:
Revised: References to K0903 crosswalked to A5514
Revised: RT and LT modifier billing instructions (Effective 03/01/2019)

04/04/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2018
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: coverage allowances for K0903
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Add: Clarifying language regarding Certifying Physician
CODING GUIDELINES:
Added: Coding guidelines for K0903
Added: PDAC verification requirements for K0903


04/26/2018:  At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Modifier instructions, Certification requirements and in-person evaluation requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Revision Effective Date: 10/01/16
ICD-10 CODES THAT ARE COVERED:
Added: New ICD-10 Diabetic codes per Annual Update
Deleted: Non-valid ICD-10 Diabetic codes per Annual Update

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 11/01/2014 (April 2015 Publication)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Reference to ICD-9 Codes in the narrative
CODING GUIDELINES
Revised: PDAC verbiage

Revision Effective Date: 11/01/2014
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Criterion 5 (in-person fitting requirement)

Revision Effective Date: 10/01/2014
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Restored: Detail Written Order Requirement