Orders and Documentation Are Vital to Diabetic Shoe Coverage

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The Durable Medical Equipment Medicare Administrative Contractors (DME MACs), who process claims for diabetic shoes, inserts, and supplies, have a Local Coverage Determination (LCD) and a Policy Article that governs coverage and payment. The reimbursement of these supplies depends on accurate orders, medical record documentation, and information provided to the supplier. Because physicians and other qualified healthcare professionals continue to query this author about ordering therapeutic shoes for their patients with diabetes, this article reviews some of the most frequently asked questions pertaining to this topic.
Q: What are the differences among a certifying physician, a prescribing practitioner, and a supplier?
A: This is a great question that confuses many.
Q:Where can I find the DME MACs’ LCD and Policy Article?
A: The LCD (Therapeutic Shoes for Persons with Diabetes [L33369]) can be found at www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33369, and the Policy Article (Therapeutic Shoes for Persons with Diabetes [A52501]) can be found at www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52501.
Q:What are the coverage criteria for therapeutic shoes, inserts, and/or modifications to therapeutic shoes?
A: Therapeutic shoes, inserts, and/or modifications to therapeutic shoes are covered if all of the following criteria are met:
1. The beneficiary has diabetes mellitus (reference diagnosis code section in Policy Article [A52501]); and
2. The certifying physician (MD or DO) has documented in the beneficiary’s medical record 1 or more of the following conditions:
a. previous amputation of the other foot, or part of either foot, or
b. history of previous foot ulceration of either foot, or
c. history of preulcerative calluses of either foot, or
d. peripheral neuropathy with evidence of callus formation of either foot, or
e. foot deformity of either foot, or
f. poor circulation in either foot; and
3. The certifying physician (MD or DO) has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes (depth or custom molded). The certifying physician must:
a. have an in-person visit with the beneficiary during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
b. sign the certification statement on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.
4. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-person evaluation of the beneficiary:
a. must take measurements of the feet for all shoes;
b. must examine the beneficiary’s feet and describe the abnormalities that need to be accommodated by shoes/inserts/modifications;
c. must take impressions, make casts, or obtain computer-aided design/computer-aided manufacturing images of the feet that will be used in creating positive models of the feet for custom molded shoes (Healthcare Common Procedure Coding System [HCPCS] code A5501) and inserts (HCPCS code A5513).
5. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results. NOTE: The supplier’s in-person evaluation must be conducted with the beneficiary wearing the shoes and inserts and must document that the shoes/inserts/modifications fit properly. A beneficiary’s subjective statements regarding fit as the sole documentation of the in-person delivery does not meet this criterion.
Q:Must the certifying physician conduct the foot examination?
A: The certifying physician must either
1. Personally document 1 or more of the qualifying foot conditions in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or
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