In our industry, toe plugs and toe fillers are frequently mixed up. Reading Medicare definitions can not only lead to confusion, but unanswered questions as well. For this exact reason, we are providing a simple break down to help you understand the differences between these two devices.
Among many reasons, it is incredibly important to understand the differences between a toe plug and toe filler because they are billed differently. To avoid hassle and frustration down the road, continue reading our simplified explanation of the differences, when to use a toe plug vs. toe filler, and the HCPCS code for each.
First, let’s take a look at the Noridian/Medicare definition of a Toefiller below:
L5000 - PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER
As noted in the descriptor, code L5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe), or the forefoot, L5000 inserts are designed to provide standing balance and toe off support for improved gait. The biomechanical control required of L5000 differs from the foot-protective function provided by inserts used as part of diabetes management.
Additionally, let’s look at the options provided by Noridian/Medicare for those diabetic patients who are missing digits:
Option 1: For diabetic beneficiaries who do not require the rigidity and support afforded by code L5000 (e.g., beneficiaries missing digits excluding the hallux), suppliers must bill code A5513 for an insert appropriately custom-fabricated to accommodate the missing digit(s). Codes L5000 or A5512 may not be billed in addition to code A5514.
Option 2: For beneficiaries missing the hallux or a forefoot that require rigidity and support for effective gait, suppliers must bill L5000 for an insert appropriately custom-fabricated to accommodate the missing digit(s) or forefoot as well as providing the foot-protective functions required for a person with diabetes. Codes A5512 or A5514 may not be billed in addition to code L5000.
What does this really mean?
Obviously the Medicare definition is fairly technical, but we can break it down pretty easily. Patient’s missing digits on either the medial or lateral sides of the foot would qualify for a toefiller. Meaning if a patient is missing digits 1,2, and 3 or digits 4 and 5, they would qualify. Patients missing digits 2, 3 or 4, would not qualify. That being said, these patients may require some level of additional support to accommodate their missing digits. In these cases, we would use a Toe Plug.
What are the billing differences? Is a toe plug billed as a different HCPCS code than a toe filler?
Please note the billing differences between the two. A toe filler is billed as HCPCS code L5000. Qualifying patients receive 1-L5000 each calendar year via Medicare. A toe plug is still billed as A5514, like the other custom accommodative diabetic inserts. Qualifying patients receive 3-A5514 inserts per foot each calendar year.
We hope this clarified some of the confusion surrounding these items. As always, if you are still unclear about which device to use for your patients, please reach out to our Customer Service Team, 1-844-637-4637, and we will be happy to clarify anything you need.