Podiatry Coding & Billing Alert

Hint: a diabetes diagnosis is a requirement for both shoe prescriptions and foot care.

Whether you are billing for diabetic foot care or diabetic shoes, the process can be complex. It requires fulfilling several conditions; otherwise, Medicare may reject your claim. It’s crucial to understand the responsibilities of the certifying doctor, supplier, and prescribing provider.

Additionally, you need to be aware of the procedures during the diabetic foot examination and the supplier’s assessment.

Take a look at these frequently asked diabetic foot care questions below to stay one step ahead.

Question 1: What criteria must be met for therapeutic shoes to be covered?

Answer: There are five criteria that must be met:

1. The patient needs to be diagnosed with diabetes mellitus, and the corresponding ICD-10 code should be included on your claim. The patient’s overall diabetic condition must be exclusively overseen by a medical doctor (MD) or doctor of osteopathic medicine (DO).

Note: If you file a claim for diabetic shoes and the beneficiary does not have diabetes, Medicare will deny your claim based upon a lack of medical necessity.

2: The certifying physician (MD or DO) must document one or more conditions (listed in sections 2a-2f of Medicare Policy Article A52501) in the patient’s medical record, or the beneficiary’s certified physician must initial, date, and indicate agreement with the records of another practitioner who conducted the foot exam.

3: The certifying physician (MD or DO) must complete the certifying physician statement and conduct an in-person visit with the patient during which diabetes management is addressed within six months prior to delivery of the shoes/inserts.

4: The supplier must conduct and document an in-person evaluation of the patient prior to selecting the items. This exam must include an examination of the patient’s feet with a description of abnormalities that will need to be accommodated by the shoes/inserts/modifications. For shoes, the documentation must include measurements of the patient’s feet. For custom-molded shoes, the documentation must include records of impressions, casts, and Computer Aided Design (CAD) and Computer Aided Milling (CAM) images of the patient’s feet.

5: The supplier must conduct an objective assessment of the fit of the shoe and inserts and then document the results at the time of in-person delivery.

Question 2: What conditions meet Medicare’s criteria?

Answer: Per Medicare Policy Article A52501, one or more of the following conditions must be present in the medical record of the practitioner who has conducted the foot exam for the patient:

• A — Previous amputation of other foot, or part of either foot; or
• B — History of foot ulceration; or
• C — History of pre-ulcerative calluses; or
• D — Peripheral neuropathy with evidence of callus formation of either foot; or
• E — Foot deformity; or
• F — Poor circulation in either foot

The documentation must clearly indicate that the condition is of the feet or foot.

Some of the codes listed to prove medical necessity include but are not limited to:

• E08.621 (Diabetes mellitus due to underlying condition with foot ulcer)
• E09.621 (Drug or chemical induced diabetes mellitus with foot ulcer)

Question 3: Can someone other than the certifying physician perform the foot exam?

Answer: While the certifying doctor can carry out this exam, this isn’t the only option. Other healthcare professionals like a podiatrist, another MD or DO, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) can perform the patient’s foot examination, then return it to the certifying doctor. The certifying doctor will then go through the medical record, initial and date it, and send it back to the practitioner or doctor who performed the foot examination.

According to Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC, in Bella Vista, Arkansas, “It is important to pay attention to the criteria and responsibility for each. For instance, the certifying physician does not need to document medical necessity in their record if not prescribing. Agreement with the prescribing provider’s documented conditions suffices for meeting criteria in their scope.”

Question 4: Can the prescribing physician also be the supplier of the shoes?

Answer: The prescribing professional can also be the provider of the durable medical equipment (DME). This is a common occurrence, as many podiatry clinics may perform the foot examination, issue the prescription for the shoes, and then have the patient return upon delivery to ensure the fit is accurate. You must understand the roles of each person when it comes to reporting diabetic shoes:

Certifying physician: The certifying physician must be an MD or DO. The certifying physician is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care. The certifying physician cannot be a podiatrist or clinical nurse specialist.

Prescribing practitioner: The prescribing practitioner writes the order for the therapeutic shoes, modifications, and inserts. The prescribing practitioner must be knowledgeable in the fitting of the diabetic shoes and inserts. They may be a podiatrist, MD, DO, PA, NP, or CNS. The prescribing practitioner may also be the supplier.

Supplier: The supplier furnishes the shoes, modifications, and/or inserts to the patient. The supplier may be a podiatrist, pedorthist, orthotist, prosthetist, or another qualified individual. The prescribing practitioner may also be the supplier.

Don’t miss: The certifying physician may only be the supplier if they are practicing in a defined rural area or a defined health professional shortage area.

Question 5: When a patient comes in for diabetic foot care, is it required for the podiatrist to document in their note who the patient’s primary care provider (PCP) is and the date the patient was last seen by that PCP?

Answer: Medicare stipulates that the patient must be under the management and oversight of a healthcare provider who is addressing the diabetes in order to be eligible for routine foot care like nail and callus treatment. Consequently, your podiatrist’s note should record the name of the patient’s PCP and the last date the patient saw the PCP, even if the date is an estimated one.

Note: Most private payers do not require this information, but many Medicare jurisdictions do require it on the claim for those with diabetes. So, it’s best to get into the habit of collecting the information.

“Medicare will require information on the claim to confirm the condition is being managed along with a timeline of treatment. This is due to frequency limitations and medical necessity, since routine foot care is only payable with specific conditions being treated,” says McNamara.

Question 6: Do diabetic shoes have to be delivered in-person to the patient?

Answer: Yes. The delivery of diabetic shoes and/or inserts must be done face-to-face. Diabetic footwear should not be mailed to the patient. It is essential that the delivery is done in-person, with the patient present to confirm the proper fit of the shoes.

During the face-to-face delivery, the provider is required to carry out an objective evaluation of the shoe and/or insert fit and record the findings. In this evaluation, the provider must document factual information regarding the fit and how the footwear will address the patient’s foot issues. The supplier needs to assess the correct fit and make note of how the insert or shoe fits the patient’s foot and accommodates foot problems the medical professional found when they performed the foot exam.

Note: The supplier’s evaluation must be made while the patient is wearing the diabetic shoes and inserts.