Podiatry Coding & Billing Alert

A podiatrist's pride is helping patients to walk comfortably, something which isn't always easy for diabetics. The good news is Medicare covers therapeutic footwear for diabetic patients -- here's a breakdown of the shoe and insert coding and billing facts.

Select the correct shoe code based on whether the extra-depth diabetic shoes you are providing are off-the-shelf or custom made. Choose from HCPCS level II codes:

• A5500 -- For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-densityinsert(s), per shoe

• A5501 -- For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe

Frequency: Medicare covers one pair of shoes per calendar year for each qualified patient. When reporting the shoes, remember to bill for two units, says Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Medicare, however, does not guarantee coverage of a new pair of shoes each year, points out Beresh. Before dispensing another pair, you must document that the prior pair of shoes need replacing because they are non-functional and/or in poor condition to qualify for Medicare reimbursement, he adds.

Don't forget: Always append modifier KX (DME POS item subject to DME POS competitive bidding program number 4) to claims for diabetic shoes and inserts, or any equipment that once required a certificate of medical necessity (CMN) or that currently requires a written order prior to delivery (WOPD).

To settle on the correct insert code, look at two details:

1. how the inserts were formed (with or without a heat source) and

2. whether they are prefabricated or custom-made. Then, choose the appropriate code from:

• A5510 -- For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe

• A5512 -- For diabetics only, multiple density insert, direct formed, molded to foot after externalheat source of 230 degrees Fahrenheit or higher,... prefabricated, each

• A5513 -- For diabetics only, multiple density insert, custom molded from model of patient's foot,...includes arch filler and other shaping material, custom fabricated, each

Frequency: Medicare covers three sets of inserts per calendar year. (For custom-molded shoes, you may provide two pairs of inserts in addition to the pair provided with such shoes). When ordering three sets of inserts, bill for a total of six units, notes Beresh.

Modifications: Instead of providing the limit of three sets of inserts per calendar year, you may also have the option of substituting modification(s) of custom-molded or depth shoes, according to the Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 140, "Therapeutic Shoes for Individuals with Diabetes" at www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf. Medicare will reimburse for the modification(s) up to the limit set for the inserts to which the individual is entitled.

Report modifications to off-the-shelf and custom-molded shoes with a code from the A5503-A5508 range, for instance:

• A5506 -- For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe

Enter the correct diabetes diagnosis code from the 250.xx range on the diabetic shoe claim form -- and pay special attention to those fourth and fifth digit numbers.

Complications: The nature of the complication is where the fourth digit comes into play. While you may most frequently treat diabetic patients with peripheral circulatory disorders (250.7x), other four digit numbers in the 250.xx range describe diabetic complications such as renal manifestations (250.4x) or neurologic manifestations (250.6x).

Disease type: The fifth digit subclassification indicates the type and level of the disease:

• 0 -- type II or unspecified type, not stated as uncontrolled

• 1 -- type I [juvenile type], not stated as uncontrolled

• 2 -- type II or unspecified type, uncontrolled

• 3 -- type I [juvenile type], uncontrolled.

Try this: If you have trouble determining the correct fifth digit number, create a sheet for the doctor to check off when seeing diabetic patients to indicate the type and level of the disease, suggests Beresh.

Just ask: Ideally, the patient's diagnosis code should match what the primary care provider (PCP) has noted in her chart. If you are not able to obtain the precise diagnosis code from the PCP office, ask the patients what type of diabetes they have and how well controlled it is, suggests Anthony Poggio, DPM, in Alameda, Calif. "These acuity codes are important in the HMO (health maintenance organization) world, as HMOS are paid based upon patient acuity of conditions," says Poggio.

Now that you know the ins and outs of coding for shoes and inserts, don't forget the PCP's certification.

While a doctor of podiatry medicine can prescribe a specific therapeutic shoe, a doctor of medicine or osteopathy must certify that the patient has diabetes, note the associated conditions, and recommend that the patient receive therapeutic footwear, says Poggio.

Documentation: The managing physician, according to the MBPM, must:

• document in the patient's medical record that the patient has diabetes

• certify that the patient is being treated under a comprehensive plan of care for diabetes, and that the patient needs diabetic shoes

• document in the patient's record that the patient has one or more of the following conditions:

• peripheral neuropathy (337.1) with evidence of callus formation (700)

• calluses (700)

• ulceration (707.1x)

• other acquired deformities of ankle and foot deformity (736.7x)

• prior amputation of the foot or part of the foot (V49.7x)

• poor circulation (440.x).

Tip: "Our office sends a letter to the PCP telling them that we are considering diabetic shoes for the patient," shares Beresh, "and requests that they verify that the patient has diabetes and that they agree that shoes are necessary and beneficial for the patient," shares Beresh.