Podiatry Coding & Billing Alert

Tip: The right shoe is crucial for averting amputations.

You are in a double bind if you often provide special prescription footwear to your patients. Not only do you need to establish the medical necessity; you need to be certain that Medicare covers the service. Find out how you can escape coding confusion with this expert advice.

Impact of Circulatory Deficiencies

Poor circulation affects the feet which should not be confused with the manifestations from other diseases of the feet such as diabetic neuropathy. Loss of protective sensation of pain and tingling sensations as well as sluggish circulation are prime indicators that your patient needs custom designed footwear to prevent or protect deformities caused by diabetes. Ulcers or gangrene caused by diabetes can even lead to amputation.

“The actual evaluation of … and treatment of this neuropathy is covered by Medicare every six months,” says Lynn M. Anderanin, CPC, CPPM, CPC-I, COSC, senior director of Coding Education for Healthcare Information Services, in an audio-conference titled “Podiatry and Foot Care: Coding, Special Coverage & Reimbursement Guidelines for 2016,” presented on behalf of Audioeducator.com in February.

Watch Out for These Indicators

As with all medical encounters, your documentation will be key to whether or not you get paid. Therefore, if you observe any of the following, remember to make a note of it:

• Diabetic foot ulcers: wounds that do not heal or become infected;
• Infections: cellulitis, osteomyelitis and/or abscesses caused by an ingrown toenail or areas of skin degeneration between the bases of the toes or break in the skin in an ulcer;
• Calluses that could lead to foot ulcers;
• Gangrene: dead tissue resulting from complete loss of circulation;
• Deformation of either or both feet caused by diabetes.

You should make a note of signs of pressure (redness, whiteness of skin or other discoloration) or skin breakdown on all skin surfaces, including the spaces between the toes and edges of toenails, to be able to establish medical necessity.

Confront Coverage Determinations

According to the “Medicare Benefit Policy Manual,” Chapter 15, Section 290, Medicare covers only medically necessary and reasonable foot care. Medicare Part B covers the furnishing and fitting of either one pair of custom-molded shoes and three pairs of inserts or one pair of extra-depth shoes each calendar year for patients diagnosed with diabetic foot. 

A MLN Fact Sheet: Medicare Podiatry Services: Information for Medicare Fee-For-Service Health Care Professionals points out, “Claims for diabetic therapeutic shoes are processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs). Therapeutic shoes for diabetics are not DME and are not considered DME or orthotics; however, there is a separate category of coverage under Medicare Part B.”

However, individual state laws govern a podiatrist’s scope of practice; thereby indirectly your fee for service structure. However, Medicare — and other payers which follow it — cover a pre-made depth-inlay shoe and three pairs of inserts, or a pair of custom molded shoes and two additional pairs of inserts within a calendar year.

To know more about the relevant coverage determinations, please see: https://www.medicare.gov/coverage/therapeutic-shoes-or-inserts.html and https://www.cgsmedicare.com/jc/mr/pdf/Thera_Shoes_DC_int.pdf.

Audits Could Catch You Flat Footed

“It’s really important that you meet all of the criteria (for dispensing therapeutic shoes). If your records are ever audited for these things and you don’t have this documentation, you could have to refund the money. The first thing that auditors want to look at is the documentation to support each claim,” Anderanin pointed out.

In March, 2010 NGS did an audit in Illinois on 215 claims regarding documentation … 11% of the claims that they asked for never submitted the documentation. Eighty-seven percent of the claims that they looked at were non-covered. So, only two percent of the claims were payable, Anderanin informed.

“If your doctors are not dictating or documenting information for the sixth character, you really need to start them doing that now,” she added.

Distinguish Your A Codes

Report 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);

For a custom molded shoe, report 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).

For a custom molded shoe with a roller or rigid rocker bottom, report 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).

For a custom molded shoe with wedges, report A5504, (For diabetics only, modification [including fitting] of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge[s], per shoe); and

Finally, code 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) for custom fabricated shoes.

The takeaway: You need to not only follow the guidelines and requirements of the codes, but also ensure that it is thoroughly documented.