## **What is a custom-molded diabetic insert?**
HCPCS code A5513 refers to "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.
These devices are custom-fabricated using a physical positive model of the patient's foot, which may be created by direct carving or a rectified CAD model created from the positive model. Inserts fabricated solely through CAD-CAM or digitized scans, without creating a physical model of the patient’s foot, are billed under HCPCS code A5514 rather than A5513.
Because A5513 falls under the therapeutic shoes for persons with diabetes benefit category, providers must follow the correct coding guidelines outlined by DME MACS and the PDAC website. Inserts under A5513 are distinguished from prefabricated inserts (A5512) by the fact that they are fully custom-molded, not off-the-shelf, and require professional expertise in shaping and fabrication to achieve proper fit and total contact with the foot.
## **HCPCS code A5513 documentation requirements**
Medicare documentation standards require:
A standard written order (SWO) signed by the treating physician or qualified healthcare provider, specifying the need for custom-molded inserts rather than prefabricated options.
Documentation confirming the patient has diabetes mellitus and at least one qualifying foot condition (e.g., history of ulceration, callus formation, pre-ulcerative lesion, neuropathy with evidence of callus, poor circulation, or amputation).
Records showing the insert was custom molded from a model of the patient's foot, either by direct carving, a rectified CAD model, or a positive mold.
Documentation that the inserts include arch filler and other shaping materials to ensure stability and therapeutic benefit
## **A5513 billing requirements**
When billing for A5513, providers should report 1 unit per insert, per foot, with a maximum of three pairs per calendar year covered by Medicare for eligible diabetic patients. The KX modifier may be appended to certify all coverage requirements are met, with RT (right) or LT (left) to specify laterality. If both feet are supplied, bill separately for each side.
Claims must include the patient’s qualifying diabetes diagnosis and documentation of custom fabrication. For centrally fabricated inserts, PDAC verification is required; if the product is not PDAC-verified, it must be billed as A9270 (non-covered item/service). Inserts fabricated and dispensed by the same supplier from raw materials do not require PDAC listing but must fully meet A5513 specifications.
## **Other relevant codes**
- **A5512**: For diabetics only, multiple density insert, prefabricated, each. This applies when inserts are off-the-shelf and not custom molded from a patient-specific model.
- **A5500**: For diabetics only, shoes (depth or custom-molded), per pair. This code covers therapeutic shoes dispensed with inserts such as A5512 or A5513.
- **A5501**: For diabetics only, custom-molded shoe, per pair. Used when the shoe itself must be fabricated for the patient’s foot.
- **A5503–A5508**: Additional codes for modifications or accessories to diabetic shoes, such as metatarsal bars, wedges, or heel stabilizers.
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