Podiatry Coding & Billing Alert

Remember: The certifying physician must be either an MD or DO.

To ensure your diabetic shoe claims are up to snuff, you'll want to understand the following important terms, provided by Michael Hanna, MPA, CDME, provider relations senior analyst at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in the "A/B-DME Collaborative Diabetic Shoes" webinar.

Define Certifying Physician for Clarity

The certifying physician, who must be either an MD or DO, is responsible for diagnosing and treating the patient's diabetic systemic condition through a comprehensive plan of care, according to Hanna. The certifying physician may not be a podiatrist, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

The certifying physician is the one who manages the patient's systemic diabetic condition. This plan of care is tailored specifically for the patient, Hanna adds.

"The plan might include insulin, or maybe they are right on the cusp of insulin, so they talk about diet and exercise," Hanna says.

The certifying physician must also complete the medical record, which discusses the patient's systemic diabetic condition. In addition, the certifying physician completes, signs, and dates the certifying physician statement.

Accurately Identify the Prescribing Practitioner

The prescribing practitioner can be the same physician who performs the patient's systemic diabetic exam. Or it can be another MD or DO. It can also be a PA, NP, CNS, or podiatrist, according to Hanna.

The prescribing practitioner is the person who writes the order for the therapeutic shoe, modifications, and inserts. The practitioner must be knowledgeable in the fitting of the diabetic shoes and inserts.

Learn the CPT^® Codes for Diabetic Shoes and Inserts

If a patient meets the coverage criteria for diabetic shoes, he may receive one of the following during the calendar year:

• One pair of 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 two additional pairs of inserts - A5512 (For diabetics only, multiple density insert, direct formed, molded to foot ...) or A5513 (For diabetics only, multiple density insert, custom molded from model of patient's foot ...); or
• One pair of depth shoes (A5500, For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe) and three pairs of inserts (A5512 or A5513). Note: These three pairs of inserts do not include the non-customized, removable inserts provided with the shoes.

"Being able to provide diabetic shoes is a great benefit for both the podiatrist and patient, but you need to follow the rules as stated or it will just be a source of frustration," says Arnold Beresh, DPM, CPC, CSFAC in Newport News, Virginia.

Who is the Supplier? Find Out

The supplier is the person or entity that furnishes the diabetic shoes, modifications, and/or inserts to the patient and bills the DME MAC based upon the patient'slocation, Hanna says. The supplier can be a podiatrist, pedorthist, orthotist, prosthetist, or other qualified individual.

"The supplier could also be a standard brick and mortar DME - a full line durable medical equipment supplier that also does hospital beds, wheelchairs, oxygen, diabetic testing supplies, etc.," Hanna says. "They would just have shoes as one line of business."

The supplier can also be the prescribing practitioner, which happens pretty frequently in the DME world, according to Hanna.

Additionally, the certifying physician can be the supplier if it's in a defined rural area or a defined health professional shortage area.