Podiatry Coding & Billing Alert

Question: One of my diabetic Medicare patients is a carpenter who requires work boots for his job. Is there a code for this type of diabetic shoe, or will he only qualify for inserts in regular work boots?

Virginia Subscriber

Answer: Coding the situation you describe can be tricky because the rules for diabetic shoes change from carrier to carrier. For the state of Virginia, you should consult CIGNA Government Services, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C, which includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia.

In terms of the footwear itself, there are three possible options for this patient. One is for the podiatrist to prescribe a hightop boot (report HCPCS code L3649, Orthopedic shoe, modification, addition or transfer, NOS), which would provide the appropriate biomechanical control to properly offload the patient's feet. For example, if a patient has a previous midfoot amputation, he needs a high-top boot to prevent his remaining foot from slipping out of his shoe or boot while walking or running.

As for inserts for his regular work boots, under the guidelines of the "Therapeutic Shoes for Persons With Diabetes" benefit, you may only bill for inserts (codes A5512 and A5513, For diabetics only, multiple-density insert ...) if the podiatrist dispenses the inserts for qualified diabetic footwear. The exact features that qualify footwear are listed on the CMS Web site or can be obtained through the regional carrier.

There is another option for the patient: what is known as the "Deluxe Feature" category under Medicare's Therapeutic Shoe Bill. The bill essentially states that if a patient requests additional upgrades to his shoe gear, the patient is financially responsible for the upgrades.