who is eligible for medicare / hcpcs code = a5500

by Alba Volkman Published 2 years ago Updated 1 year ago

What does a5500 code mean on HCPCS?

HCPCS Code Details - A5500 Coverage code D - Special coverage instructions apply BETOS 2 code D1F - Prosthetic/Orthotic devices HCPCS Action code N - No maintenance for this code Type of service J - Diabetic shoes 9 more rows ...

What is the HCPCS code for for diabetics only?

A5500 is a valid 2021 HCPCS code for 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 or just “ Diab shoe for density insert ” for short, used in Diabetic shoes .

Can I Bill a5507 for therapeutic shoes for persons with diabetes?

HCPCS code A5507 must not be used to bill for this service (see the medical policy on Therapeutic Shoes for Persons with Diabetes for details).

What is an HCPCS code?

Different sets of Healthcare Common Procedure Coding System (HCPCS) codes are used to identify the shoes, modifications, and inserts that may be eligible for payment. The determination as to which HCPCS code (s) must be utilized depends on the benefit category within which the shoes, modifications, and inserts qualify for coverage.

What is Medicare Hcpcs code A5500?

Propét Men's Stability Walker Medicare/Hcpcs Code = A5500 Diabetic Shoe Sneaker.

Are custom foot orthotics covered by Medicare?

Medicare Part B pays for 80 percent of the approved cost of either custom-made or pre-made orthotic devices. Of course, this is only possible if your health care provider feels it is medically necessary. Medicare categorizes orthotics under the durable medical equipment (DME) benefit.

Who can write prescription for diabetic shoes?

The prescribing practitioner may be a podiatrist, MD, DO, physician assistant (PA), licensed nurse practitioner (LPN), or clinical nurse specialist (CNS). The prescribing practitioner may also be the supplier (i.e., the one who furnishes the footwear).

What are requirements for diabetic shoes?

Your doctor confirms your need for therapeutic shoes or inserts. A podiatrist or other qualified doctor prescribes them....You have least one of the following conditions in one or both feet:Partial or total foot amputation.Foot ulcers.Pre-ulcerative calluses.Nerve damage due to diabetes.Poor circulation.Foot deformity.

Does Medicare cover orthotics 2021?

Does Medicare Cover Orthotics? Orthotics are devices used to treat injured muscles and joints. Medicare will typically cover 80 percent of the costs for orthotic devices under Medicare Part B if they are deemed medically necessary by a doctor.

Does Medicare pay for orthotic shoe inserts?

For the most part, Medicare does not cover orthopedic or inserts or shoes, however, Medicare will make exceptions for certain diabetic patients because of the poor circulation or neuropathy that goes with diabetes.

Are diabetic shoes considered DME?

Claims for therapeutic shoes for diabetics are processed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs). Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics, but a separate category of coverage under Medicare Part B.

What is the difference between diabetic shoes and regular shoes?

Diabetic shoes are often wider and deeper than regular shoes to accommodate a special multi-density insert that is designed to reduce pressure and callouses to the bottom of feet. Diabetic shoes have a larger “toe box” to prevent squeezing of the toes.

Will insurance cover diabetic shoes?

HOW TO GET YOUR DIABETIC SHOES THROUGH YOUR INSURANCE: If you are diabetic and have Medicare and Medicaid, you could be eligible for a pair of shoes and 3 pairs of moldable insoles. It is that easy! All you have to do is bring in your insurance cards and a prescription from your doctor.

What is A5500 diabetic shoe?

A5500 is a standardized code for Medicare and other health insurance providers to provide healthcare claims. Diabetic shoes (sometimes referred to as extra depth, therapeutic shoes or Sugar Shoes) are intended to reduce the risk of skin breakdown in diabetics with pre-existing foot disease.

Does Social Security pay for diabetic shoes?

Therapeutic Shoes and inserts are covered under the Therapeutic Shoes for Individuals with Diabetes benefit (Social Security Act §1861(s)(12)).

Can a podiatrist prescribe diabetic shoes?

The doctor who treats your diabetes must certify your need for therapeutic shoes or inserts. A podiatrist (foot doctor) or other qualified doctor must prescribe the shoes or inserts, and you must get the shoes or inserts from one of these: A podiatrist. An orthotist.

General Information

Article Guidance

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

ICD-10-CM Codes that Support Medical Necessity

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the Non-Medical Necessity Coverage and Payment Rules section for other coverage criteria and payment information.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

What is Medicare approved amount?

Medicare-Approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B.

What is original Medicare?

Your costs in Original Medicare. An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Does Medicare cover therapeutic shoes?

Medicare will only cover your therapeutic shoes if your doctors and suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren't enrolled, Medicare won't pay the claims submitted by them. It's also important to ask your suppliers ...

Does Medicare cover custom molded shoes?

One pair of custom-molded shoes and inserts. One pair of extra-depth shoes. Medicare also covers: 2 additional pairs of inserts each calendar year for custom-molded shoes. 3 pairs of inserts each calendar year for extra-depth shoes. Medicare will cover shoe modifications instead of inserts.

Do suppliers have to accept assignment for therapeutic shoes?

It's also important to ask your suppliers if they participate in Medicare before you get therapeutic shoes. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren't "participating," they may choose not to accept assignment.

What is the code for a covered leg brace?

Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, L3225) are covered in these situations.

What are the L codes for ORF?

Both the TSD and ORF related Policy Articles address these points. From TSD Policy Article. Codes for inserts or modifications (A5503 – A5508, A5510, A5512, A5513) may only be used for items related to diabetic shoes (A5500, A5501).

Can KX modifier be used on shoes?

A KX modifier must not be used in this situation. Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010-L5600) which is attached to the residual limb by other mechanisms because there is no Medicare benefit for these items.

Does Medicare cover shoes?

Medicare has limited coverage provisions for shoes used by beneficiaries. Section 1862 (a) (8) of the Social Security Act (SSA) says: [N]o payment may be made under part A or part B for any expenses incurred for items or services … where such expenses are for orthopedic shoes or other supportive devices for the feet, ...

Can a matching shoe be billed with a KX modifier?

A matching shoe which is not attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as noncovered because coverage is statutorily excluded. Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace.

What happens if you see a doctor in your insurance network?

If you see a doctor in your plan’s network, your doctor will handle the claims process. Your doctor will only charge you for deductibles, copayments, or coinsurance. However, the situation is different if you see a doctor who is not in your plan’s network.

Can you get a surprise bill from a doctor?

However, occasionally you may receive a surprise bill from a doctor that was involved in your inpatient treatment. If this happens, contact the doctor and find out if they accept Medicare assignment and if and when they plan to submit the claim to Medicare.

Does Medicare cover out of network doctors?

Coverage for out-of-network doctors depends on your Medicare Advantage plan. Many HMO plans do not cover non-emergency out-of-network care, while PPO plans might. If you obtain out of network care, you may have to pay for it up-front and then submit a claim to your insurance company.

Do participating doctors accept Medicare?

Most healthcare doctors are “participating providers” that accept Medicare assignment. They have agreed to accept Medicare’s rates as full payment for their services. If you see a participating doctor, they handle Medicare billing, and you don’t have to file any claim forms.

Do you have to pay for Medicare up front?

But in a few situations, you may have to pay for your care up-front and file a claim asking Medicare to reimburse you. The claims process is simple, but you will need an itemized receipt from your provider.

Do you have to ask for reimbursement from Medicare?

If you are in a Medicare Advantage plan, you will never have to ask for reimbursement from Medicare. Medicare pays Advantage companies to handle the claims. In some cases, you may need to ask the company to reimburse you. If you see a doctor in your plan’s network, your doctor will handle the claims process.

Can a doctor ask for a full bill?

In certain situations, your doctor may ask you to pay the full cost of your care–either up-front or in a bill; this might happen if your doctor doesn’t participate in Medicare. If your doctor doesn’t bill Medicare directly, you can file a claim asking Medicare to reimburse you for costs that you had to pay.