A5500 CPT Code Reimbursement Explained

Diabetic footwear is crucial for preventing foot complications in diabetic patients. Medicare and insurance providers cover diabetic shoes and inserts under the A5500 CPT code. This code covers custom fitted shoes, depth-inlay shoes, and multi-density inserts for diabetics.

Key takeaways:

• A5500 is the HCPCS code for diabetic depth-inlay shoes with removable inserts. This code covers the fitting, preparation, and supply of these specialized shoes.
• Diabetic footwear helps prevent foot ulcers and amputations. Proper footwear redistributes pressure and reduces friction on the feet.
• Medicare provides coverage of diabetic shoes for patients with diabetes who meet certain requirements. Other insurance plans also cover diabetic shoes but may have different criteria.
• The A5500 code can be used once per calendar year per patient for one or both shoes. Inserts and other modifications have additional codes.

What is the A5500 Code for Diabetic Shoes?

A5500 is the Healthcare Common Procedure Coding System (HCPCS) code for depth-inlay diabetic shoes fitted to accommodate removable inserts. This code covers:

• Initial fitting and assessment for custom diabetic shoes
• Custom preparation and supply of the depth-inlay shoes
• Follow-up visits to check fit and function

The A5500 code is for off-the-shelf depth-inlay shoes specifically made for diabetics. The shoes are customized with multi-density inserts to redistribute pressure away from areas prone to ulcers.

This code can be used once per calendar year per patient, whether one or both shoes are supplied. Other HCPCS codes exist for the inserts and shoe modifications.

What Footwear Does A5500 Cover?

To qualify for A5500 diabetic shoes, certain Medicare coverage criteria must be met:

• The patient must have a diagnosis of diabetes with neuropathy, poor circulation, or history of foot ulcer or amputation.
• The certifying physician must document the need for diabetic shoes in a detailed written order.
• Depth-inlay shoes must be fitted and customized by a podiatrist or trained orthotist.

The A5500 shoes are off-the-shelf therapeutic footwear customized for the patient. The shoes have a full-length, heel-to-toe multi-density insert that redistributes pressure.

This code covers the fitting, preparation, and supply of these shoes. It does not include the insert, which is billed separately.

Does Medicare Cover A5500 Diabetic Shoes?

Yes, Medicare Part B covers diabetic shoes and inserts for patients who meet specific eligibility criteria. Coverage is limited to one pair of shoes and up to 3 pairs of inserts per year.

To qualify for Medicare coverage of A5500 diabetic shoes:

• The patient must be diagnosed with diabetes.
• The patient must have one of the following conditions:
  • Peripheral neuropathy with evidence of callus formation
  • History of pre-ulcerative calluses
  • History of previous foot ulceration
  • Foot deformity
  • Previous amputation of the foot or part of the foot
  • Poor circulation
• The certifying physician must document the need for diabetic shoes and inserts in the patient’s medical record through a detailed written order.

Do Other Insurance Plans Cover A5500 Shoes?

Many private insurance plans also cover diabetic shoes but may have different eligibility requirements than Medicare. Some key points:

• Coverage, deductibles, and copays for A5500 shoes can vary significantly between insurers. Patients should check their policy.
• Preauthorization may be required before getting diabetic footwear.
• Replacements may not be allowed within a certain timeframe, such as 6 months or 1 year.
• Insurance may require use of approved suppliers and limit coverage from out-of-network providers.

Regardless of insurance type, the A5500 code can only be billed once per patient per calendar year. Additional supplies and mods have separate codes.

Can I Get Diabetic Shoes Without Insurance Coverage?

For patients who do not qualify for Medicare or insurance coverage of diabetic footwear, out-of-pocket costs apply. Options include:

• Checking with the manufacturer for patient assistance programs or discounts.
• Looking for coupons from diabetic shoe suppliers.
• Seeing if related costs, like exams or fittings, can be covered.
• Considering less expensive over-the-counter diabetic shoes. These do not use the custom A5500 code but still help protect feet.

Talk to your provider about ways to get diabetic footwear at more affordable prices if coverage is denied. Preventing foot complications is crucial for diabetes management.

The Takeaway on A5500 Diabetic Shoes

Proper footwear is vital for diabetics at risk for foot ulcers and amputation. The A5500 CPT code covers specialized fitting, preparation, and one pair of multi-density depth-inlay shoes per year.

Medicare provides coverage for patients who meet eligibility criteria. Other insurance plans also cover diabetic shoes under A5500 but have variable requirements.

Diabetic footwear helps redistribute pressure and reduce friction to avoid foot issues. Despite insurance barriers, patients should do everything possible to get therapeutic shoes. Talk to your provider about prescription and coverage options.