Podiatry Coding & Billing Alert

Hint: The patient must have documented diabetes mellitus diagnosis to qualify for diabetic shoes.

If you’ve ever struggled with understanding the documentation requirements for billing diabetic shoes, several A/B and DME Medicare Administrative Contractors (MACs) recently held a collaborative webinar titled “Therapeutic Shoes for Persons With Diabetes” to help answer all of your most burning questions.

Read on to learn more.

Meet These 5 Criteria for Therapeutic Shoes

Five specific criteria must be met for therapeutic shoes to be covered, according to Courtney Willis, outreach educator at the MAC Noridian. They are as follows:

• Criteria 1: The patient must have a diabetes mellitus diagnosis. You should list the appropriate ICD-10 code on your claim. The patient’s systemic diabetic condition must also only be managed by an MD or DO.
• Criteria 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.
• Criteria 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 was addressed within six months prior to delivery of the shoes/inserts.
• Criteria 4: The supplier must conduct and document in-person evaluation of the patient prior to selecting the items. This exam must include 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.
• Criteria 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.

Delve Into Conditions 2A-2F

As discussed above, one or more the following conditions 2a-2f 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, Willis adds.Understand Therapeutic Shoe Allowance

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:

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, and these shoes are covered when the patient has a foot deformity that cannot be accommodated by a depth shoe, according to Willis. The nature and severity of the deformity must be well documented in the patient’s medical record and available upon request. Don’t miss: 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) for prefabricated inserts. And, the covered custom fabricated inserts include 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) or 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). or

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

Understand Physician Documentation Requirements

The physician’s documentation for therapeutic shoes must follow certain requirements. They are as follows:

• Standard written order. Note: When the practitioner is the supplier as well, a separate order is not required, but the item provided must be clearly noted in the patient’s record, Willis says.
• Certified physician statement. This must be completed and signed by MD or DO on or after the in-person visit and within three months of delivery of the items.
• Medical records from the certifying physician documenting the comprehensive plan of care for the diabetic condition within six months prior to the delivery of shoes and the specific condition 2a-2f from Policy Article A52501.

Remember: When the prescribing physician or practitioner is not the certifying physician who conducted the foot exam, then the certifying physician must obtain the medical records, which documents the conditions 2A-2F from the podiatrist, MD, DO, physician assistant, nurse practitioner, or clinical nurse specialist, according to Willis. The certifying physician must then initial, date, and indicate agreement with the records of in-person visit with that practitioner prior to or on the same day as signing the certification statement.