May 6, 2005
Medical Resources Ltd.
895 Home Ave.
Akron, Oh 44310
Re: Stride-Lite Custom Molded Inserts
(Model CMI-5000)
Dear Ms. Rafferty:
This letter is in response to your recent inquiry for coding verification of the above listed product distributed by your company. The Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) has reviewed the documentation and information submitted for HCPCS Coding. The SADMERC conducts reviews of products to determine the correct HCPCS codes(s) of DMEPOS product(s) for Medicare billing.
It is our determination that Medicare HCPCS Code(s) to bill the four Durable Medical Equipment Regional Carriers (DMERCs) is/are:
K0629
For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with the 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.
This HCPCS coding decision applies to the submitted product(s) as presented to and reviewed by the SADMERC. Any modifications to the products could change the HCPCS code and would need to be reviewed for coding verification. The assignment of a HCPCS code to the product(s) by SADMERC or Medicare, nor does it imply or guarantee claim reimbersment or coverage. For questions regarding claim coverage or reimbursement please contact your local DMERC.
Should you disagree with this coding decision, a re-review of the product(s) can be initiated. The SADMERC will provide a re-review if the request is made within 45 days of the date of this letter and additional documentation is provided supporting the request. If a request for re-review is made after 45 days, the request is treated as a new Coding Verification Review and a complete application must be submitted along with the additional documentation supporting the request.
Palmetto GBA
Statistical Analysis Durable Medical Equipment Regional Carrier
Post Office Box 100143 • Columbia, SC • 29202-3143
