Podiatry Coding & Billing Alert

Certifying physician must be MD or DO.

When you bill for diabetic shoes in your podiatry practice, you must make sure you follow all of Medicare’s very specific rules or your claim could be denied. For example, you must append certain modifiers to the codes.

Follow these handy tips to keep your diabetic shoe claims in tip-top shape.

Tip 1: Discover Coverage Rules

Therapeutic shoes, inserts, and/or modifications to therapeutic shoes will be covered only if all of the five standards are met, per Policy Article A52501.

1. The patient has a diabetes mellitus diagnosis.

2. The certifying physician (MD or DO) must document in the patient’s medical record one or more conditions 2a-2f from Policy Article A52501; 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 must have an in-person visit with the patient during which diabetes management is addressed within six months prior to delivery of the shoes/inserts. The certifying physician must also sign the certification statement on or after the date of the in-person visit and within three months prior to the delivery of the shoes/inserts.

4. Before selecting the specific items, the supplier must conduct and document an in-person evaluation of the patient, which includes an exam of the patient’s feet with a description of the 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 CAD-CAM images of the patient’s feet.

5. At the time of in-person delivery to the patient of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results. Note: The patient’s subjective statements about the fit as the only documentation of the in-person delivery does not meet this criterion.

Modifier alert: If all of the above criteria have been met, then suppliers must append modifier KX (Requirements specified in the medical policy have been met) to codes for shoes, inserts, and modifications. They must have this documentation available upon request.

On the other hand, if all of the criteria have not been met, then you should add modifier GY (Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit) to the codes.

Not including the appropriate modifier on your diabetic shoe claim will result in it being rejected for missing information.

Tip 2: Delve Into Which Codes to Report

The allowance for therapeutic shoes for patients who meet the coverage criteria is limited to one of the following within one calendar year, which is January-December, according to Policy Article A52501:

1. 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)). The A5501 includes the inserts provided with the shoes. Two additional pairs of inserts are also covered under this benefit. These can include A5512 (For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each) through A5514 (For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, 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) for custom fabricated inserts).

2. 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-A5514, not including the non-customized removable inserts provided with the shoes.

“Like with other medical equipment covered under Medicare Part B, diabetic shoes and inserts are generally covered for 80 percent of the allowed amount,” says Jeri L. Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia. “This leaves the patient — or the Medicare supplement — responsible for the remaining 20 percent. Many supplemental plans require a prior authorization for diabetic shoes. To avoid any denials, obtain your approval prior to ordering the shoes.”

Additionally, it is good practice to have the patient sign a durable medical equipment (DME) waiver form, declaring that the patient has not received any other diabetic shoes during the current year, Jordan adds. Centers for Medicare & Medicaid Services (CMS) puts the responsibility on the provider to educate the patient before they incur charges.

Tip 3: Understand These Different Roles

When it comes to reporting diabetic shoes, different individuals will be involved in the patient’s care, and you must understand the role of each in order to bill the claim correctly.

Certifying physician: The certifying physician must be a doctor of medicine (MD) or doctor of osteopathy (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. The prescribing practitioner may be a podiatrist, MD, DO, physician assistant, nurse practitioner, or clinical nurse specialist. 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 other qualified individual. The prescribing practitioner may also be the supplier.