Podiatry Coding & Billing Alert

Make sure not to exceed the limit set for the individual per calendar year.

Diabetics may be thanking your podiatrist for helping them walk with confidence again, curtsey the various orthotic supports and diabetic footwear, but you may be feeling the pain while negotiating the Medicare billing procedures. We simplify your choices and help you make the right decisions for your practice as well as the patients with a lowdown on the shoe and insert coding and billing facts.

Say Hello to the A Codes

If a beneficiary has Medicare Part B, has diabetes, and meets certain conditions, Medicare provides benefits for diabetic shoes (shoes, fitting, and modifications), and for multiple-density inserts used in conjunction with diabetic shoes. The types of shoes that are covered per calendar year include one of the following:

• One pair of depth-inlay shoes and three pairs of inserts; or 
• One pair of custom-molded shoes (including inserts) if the beneficiary cannot wear depth-inlay shoes because of a foot deformity and two additional pairs of inserts.

Note: In certain cases, Medicare may also cover shoe modifications instead of inserts.

If your podiatrist has prescribed depth-inlay diabetic shoes, you will choose the correct shoe code depending on whether the shoe is ready made or custom made. You have a choice of two 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 
  

Further, if the podiatrist has advised modifications to the readymade or custom-molded shoes, you will look at these codes

• A5503 -- For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
  
• A5504 -- For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe
  
• A5505-- For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe
  
• 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
  
• A5507 -- For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe
  
• A5508 -- For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe.
  

Note: Some Medicare Administrators such Wellmark may allow benefits for two pairs of diabetic shoes per calendar year. However, Wellmark does not allow benefits for deluxe features code A5508. Therefore, make sure to check with your local administrator for individual rules.

You are also allowed to bill a fixed number inserts along with the shoes. You should check for two details before deciding the correct insert code, first, whether the inserts were formed with or without a heat source and second, 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.
  

Coding tip: When reporting the shoes, remember to bill for two units for each pair. Similarly, you should bill for a total of six units when reporting three sets of inserts.

According to Medicare rules, an individual may substitute modification(s) of custom-molded or depth shoes instead of obtaining a pair(s) of inserts in any combination. Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled. 

Cover Your Tracks With the Correct Diagnosis

Medicare will allow the payment for diabetic shoes/inserts if the diagnosis codes submitted with the claim are part of the list of covered diagnoses. 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.

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 commonly allowed covered diagnoses are 250.6x (Diabetes with neurological manifestations) and 250.8x (Diabetes with other specified manifestations).

Disease type: ICD-9 has allotted the fifth digit for classifying 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.

Check whether the physician who made the diagnosis has mentioned any or more of the following:

• 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).

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.

Doggedly Pursue Your Documentation 

Even after fulfilling all the conditions for a watertight claim, you may give it all away just for the need for documenting it properly. Make sure that the doctor treating the beneficiary’s diabetes documents the following points diligently: 

1. The patient has diabetes; 

2. The patient has at least one of the following conditions in one or both feet: 

• Partial or complete foot amputation; 
• Past foot ulcers; 
• Calluses that could lead to foot ulcers; 
• Nerve damage because of diabetes with signs of problems with calluses; 
• Poor circulation; or 
• Deformed foot.

1. 2. 3. The patient is being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes.

Medicare does not guarantee coverage of a new pair of shoes each year. Before reporting a new replacement 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.

Choose the Correct Source for Certifying Patient Eligibility

You may now well be on top the coding basics for shoes and inserts but you may find your well-prepared claim rebound in a flash if the shoe advice is not certified by proper medical personnel.

According to Medicare: 

• Following certification by the physician managing the patient’s systemic diabetic condition, a podiatrist or other qualified doctor must prescribe the shoes (the name of the M.D. or D.O. who diagnosed the complicating condition must be submitted with the claim, along with the approximate date that the beneficiary was last seen by the indicated physician (when active care is required), and 
• A doctor or other qualified individual like a pedorthist, orthotist, or prosthetist must fit and provide the shoes to the beneficiary. 

Take Care of Modifiers

Always check for any applicable modifier such as 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).