Podiatry Coding & Billing Alert

Hint: To qualify for diabetic shoes, the patient must have a diabetes diagnosis.

If your podiatry practice sees patients who qualify for diabetic shoes and inserts, you'll want to make sure you're up-to-date on the latest info to keep your claims clean. Take a look at the following five coverage requirements, garnered from a recent "A/B-DME Collaborative Diabetic Shoes" webinar.

Editor's note: The following requirements are also outlined in local coverage determination (LCD) L33369 and Policy Article A52501. Additionally, A52501 emphasizes that if all five requirements are not met, the therapeutic shoes, inserts and/or modifications will be denied.

Requirement 1: Don't Forget Diabetes Mellitus Diagnosis

To qualify for diabetic shoes and inserts, the patient must have diabetes mellitus (one of the ICD-10 codes listed in the LCD), said Michael Hanna, MPA, CDME, provider relations senior analyst at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in the webinar.

The LCD identifies a lengthy list of covered ICD-10 codes, which includes E08.00 (Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma [NKHHC]) through E13.9 (Other specified diabetes mellitus without complications).

Along with the diabetes diagnosis requirement, a M.D. or D.O. must also be managing the patient's systemic diabetic condition, according to Hanna.

Requirement 2: Remember the Exam for Qualifying Foot Conditions

During an in-person visit within six months prior to the delivery of the shoes and inserts and prior to or on the same day as signing the certification statement, the certifying physician must document that the patient has one or more of the following foot conditions:

• Previous amputation of the other foot, or part of either foot
• History of previous foot ulceration of either foot
• History of pre-ulcerative calluses of either foot
• Peripheral neuropathy with evidence of callus formation of either foot 
• Foot deformity of either foot 
• Poor circulation in either foot.

Note: The medical record doesn't necessarily have to be the certifying physician's medical record, according to Hanna.

The certifying physician can obtain the medical record of the foot exam, which documents one or more of the foot condition criteria, from the podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist who performed the in-person visit within six months prior to delivery of the shoes and inserts, initial it, date it (prior to signing the certification statement), and indicate his agreement with the record, Hanna says.

Requirement 3: Always Include a Certifying Physician Statement

The certifying physician, who must be an M.D. or D.O. and who is managing the patient's systemic diabetic condition, must certify the following details, according to Hanna:

• The patient has diabetes mellitus
• The patient has a qualifying foot condition
• The certifying physician is treating the patient under a comprehensive plan of care for his diabetes
• The patient needs diabetic shoes.

Requirement 4: Recognize the Importance of In-Person Evaluation for Shoe Selection

Before choosing the specific items to be provided, the supplier must conduct and document an in-person evaluation of the patient. According to Hanna, the supplier must include the following information in his documentation:

• An examination of the patient's feet with adescription of the abnormalities the shoes, inserts, and modificationswill accommodate
• For all shoes, the supplier must take measurements of the feet
• For custom molded shoes (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) and inserts (A5513, For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with 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), the supplier must take impressions, make casts, or obtain CAD-CAM images of the feet to be used in creating positive models.

Caution: The supplier's in-person evaluation of the patient at the time of delivery must be conducted with the patient wearing the shoes and inserts, and the supplier must document that the shoes, inserts, and modifications fit properly, the LCD adds.

The diagnosis code that justifies the need for these items must be also included on your claim, according to the LCD.

Requirement 5: The Supplier Must Conduct Objective Assessment of Shoe Fit

When the selected items are delivered in-person to the patient, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document these results, Hanna says.

"This is more than a statement from the beneficiary indicating how the shoes fit," Hanna adds. "This objective assessment must indicate how the diabetic shoes will accommodate the beneficiary's feet and note how the foot conditions will be lessened or alleviated."