Therapeutic Shoe Program

Diabetic Shoe 2019 Fee Schedule Shoes with Pre-Fab Inserts A5500-$73.21 1 Right and 1 Left A5512-$29.86 3 Right and 3 Left Total allowable $325.58

Diabetic Shoe 2019 Fee Schedule Shoes with Custom Diabetic Inserts A5500-$70.57 1 Right and 1 Left A5513 or A5514-$44.56 3 Right and 3 Left Total allowable is $413.78 Average profit is $230

Diabetic Shoe 2019 Fee Schedule A5501 Custom Shoe includes one pair of custom inserts- $219.59 right and left. A5503-A5507 Shoe Modifications $36.24. This code replaces one set of inserts when required. L5000 Toe Fill Insert - $511.67

Therapeutic Shoe Program

Coverage Criteria Patient has Diabetes Mellitus. Patient has one or more of the following conditions documented by the certifying physician: a. Previous amputation b. History of previous ulceration c. History of pre-ulcerative callous d. Peripheral neuropathy with evidence of callus formation of either foot e. Foot deformity f. Poor circulation in either foot

Coverage Criteria 3. A certifying statement signed by certifying physician (MD or DO only) that criteria 1 and 2 are met and patient is being managed for their diabetes. Patient must have had face-to-face office visit with the certifying physician within 6 months prior to delivery of shoes/inserts, and receive their shoes within 3 months of the signature date of the Statement of Certifying Physician.

Coverage Criteria 4. Prior to patient selecting items, supplier must conduct and document an in-person evaluation. 5. At time of delivery, supplier must conduct and document an in-person visit to dispense items.

Requirements for Depth Shoes-A5500 Full length, heel-to toe filler which provides a minimum of 3/16” of additional depth Made from leather or suitable material Has shoe closure Available in full and half sizes with a minimum of 3 widths Custom Shoe (A5501) is constructed over a positive mold

Prefabricated Insert-A5512 Total contact Multiple density Prefabricated Heat moldable PDAC approved Must be heated using an external heat source such as a heat gun or toaster oven and molded to the patient’s foot.

Custom Fabricated Insert-A5513/A5514 Total contact Multiple density Must be PDAC approved Document reason for custom inserts Missing toes or partial foot amputation inserts code L5000. Must document how the impression of the patient’s foot was made either using a foam box, plaster cast or scan.

Allowance per Calendar Year One pair of depth shoes (A5500) and three pairs of inserts (A5512 or A5513/A5514) Modifications may be covered as a substitute for an insert A5503-Rigid Rocker Bottom, Roller Bottoms A5504-Wedges A5505-Metatarsal bars A5506-Offset Heels A5507 Other modification

Custom Molded Shoes A5501 right and left Patient must have a deformity that cannot be accommodated by a depth shoe Must be well documented in suppliers records Can bill for 2 additional pair of A5512 or A5513/A5514 per calendar year.

Separate Inserts May be covered and dispensed independently of diabetic shoes if: Supplier documents patients has appropriate footwear for the inserts Footwear has to meet PDAC guidelines for depth shoes.

Certifying Physician Prior to signing certification statement Certifying physician must: Personally document in medical record one or more of the criteria a-f OR -Obtain, initial/sign, date and indicate agreement with medical records of a DPM, other MD, DO, PA, NP or CNS that documents one of more of criteria are met

Prescribing Physician Writes the order for shoes and inserts Knowledgeable in fitting May be: Podiatrist, MD or DO, PA, NP or CNS May also be the supplier

Supplier Person that furnishes the shoes and inserts Bills Medicare May be: Podiatrist Pedorthist Orthotist Prosthetist Other qualified Individual Prescribing physician may also be the supplier

Modifiers Use LT=Left Side and RT=Right side. These must be used for both shoes and inserts. When dispensing a pair of shoes, bill 2 units for shoes and 6 units for inserts Use KX modifiers when criteria requirements have been met and GY if not met. EY=no heath care provider order for this item. Claim will be denied as order is required.

Documentation Detailed written order needed each year Beneficiary’s name Physician Name Date of order Quantity and description of the item(s) Physician signature and date Written order can be in your detailed clinical examination

Sample clinical exam Date of Exam: Patient Name:   Subjective: Patient returns the office for a diabetic foot exam and diabetic therapeutic shoes and inserts. Objective: Dystrophic discolored nails 1-5 bilateral. Nails have subungual debris and do not cause discomfort due to neuropathy. Posterior Tibial pulse 1/4 bilateral. Dorsalis Pedis Pulse 1/4 bilateral. Capillary filling time of hallux prolonged (4 seconds) bilateral and diminished hair growth of legs. Using a Semmes-Weinstein 5.07 monofilament nylon wire, sharp and dull sensation was decreased on both feet. Vibratory sense was decreased at first MPJ using a tuning fork. Pes Planus and second metatarsal plantarflexed with asymptomatic callus. Decreased fat pad and hammertoes 2,3,4 bilateral. Using a Branock device, feet measured heel to toe size 10, heel to ball, size 9.5 and width, wide. Assessment: Peripheral neuropathy and peripheral vascular disease secondary to type 2 diabetes. Plantarflexed second metatarsal head causing hyperkeratosis with risk of ulceration if not off-loaded appropriately. Mycotic nails 1-5 bilateral. Plan: Debrided mycotic nails 1-5 bilateral. Debrided hyperkeratosis (grade 0 ulcer) sub second metatarsal bilateral. No underlying infection noted. Ordered therapeutic diabetic shoes (New Balance 813 white, 10D) and 3 pairs of custom diabetic inserts. Took foam impression for custom diabetic inserts to off-load second metatarsal head bilateral with aperture and metatarsal pad to reduce the risk of plantar ulceration. Prefabricated inserts would not provide enough protection for my patient. Patient qualifies for diabetic shoes due to pre ulcerative callus. The patient will receive the shoes when all paperwork is filled out by her PCP. Return to office 9 weeks for continued diabetic foot care. Dr. Jones agrees with this exam and that the patient qualifies for a pair of diabetic shoes and inserts. Joe Smith, DPM Date signed__________________ Seth Jones, MD Date signed____________________

Documentation Signed statement from certifying physician specifying the patient: Has diabetes Has a condition defined in coverage criteria Being treated under comprehensive plan of care for diabetes Needs diabetic shoes

Documentation In-person evaluation at time of selection must document: Examination of patient’s feet Measurements of patient’s feet in size and width How foot impressions was obtained for custom inserts if ordered.

Documentation In-person evaluation at time of delivery with patient wearing shoes and inserts documenting proper fit and inlcude an objective assessment of the fit. This medical record will be required in an audit as shoes and inserts must be be custom fit.

SAMPLE DELIVERY PROGRESS NOTE FOR SHOES AND CUSTOM INSERTS Patient returns to office for pick up of diabetic shoes and inserts. Patient was fitted with New Balance WW813WT size 10D and custom inserts.   The inserts matched the sole of the foot and the aperture and metatarsal pads were correctly placed to off-load the second metatarsal head bilateral. The custom inserts fit well within the shoes. The patient was fitted with both the inserts and shoes and there were no areas of excess pressure noted, nor when the patient ambulated down the hallway. The heel fit snug and there was ample room in the toe box. The patient found both the shoes and custom inserts comfortable and supportive. Appropriate paperwork was signed today by the patient including the warranty form and proof of delivery form. Patient to return for their diabetic routine foot care appointment and instructed to inspect the sides and bottom of their feet in the evening to ensure there is no skin irritation from the inserts or shoes. Patient told to call the office immediately if any problems or questions arise concerning her shoes, inserts and feet in general. FOR SHOES AND PRE-FAB INSERTS Patient returns to office for pick up of diabetic shoes and inserts. Patient was fitted with New Balance WW813WT size 10D and prefabricated diabetic inserts. The inserts were heated with a heat gun (or an oven) and the inserts were molded to the foot in a semi-weightbearing manner (patient sitting in a chair). The inserts were placed on a foam cushion and I placed both feet on the inserts and had the patient place mild weight on the inserts while holding the foot in a neutral position with heel close to vertical to provide a more supportive arch. The inserts were removed after they have cooled and held their shape and the exact same procedure was done to the next two pairs.   The patient was fitted with both the inserts and shoes and there were no areas of excess pressure noted, nor when the patient ambulated down the hallway. The heel fit snug and there was ample room in the toe box. The patient found both the shoes and custom inserts comfortable and supportive.  Appropriate paperwork was signed today by the patient including the warranty form and proof of delivery form. Patient to return for their diabetic routine foot care appointment and instructed to inspect the sides and bottom of their feet in the evening to ensure there is no skin irritation from the inserts or shoes. Patient told to call the office immediately if any problems or questions arise concerning her shoes, inserts and feet in general.

Proof of Delivery Supplier Standard # 12 Required to verify your beneficiary received DME item(s) you are billing for. Must be available upon request Maintain document for 7 years Most important document in your chart.

Contents of Proof of Delivery Patient’s name Quantity delivered Detailed description of item delivered Brand name and serial number Date of signature by beneficiary or designee signing, must be date they received item(s) Date of service = date of delivery

Beneficiary Authorization Beneficiary must authorize supplier to bill Medicare Sign and date item 12 on the CMS-1500 claim form or Signature on File One time authorization Statement from beneficiary authorizing Medicare benefits to be paid to themselves or the supplier

Recapping Clinical Exam for the DPM Include in exam why the patient qualifies for diabetic shoes and inserts. Document what you are ordering for patient. Document the measurements of the patient’s feet in size and width. If ordering custom inserts, include how foot impression or scan was obtained and why the patient needs them. Create an area on the exam for the patient’s MD to sign, date and agree with your exam.

Recapping Documentation for the DPM Fax your medical exam note and certifying statement to PCP or ENDO to request they be signed and dated. Also request the last medical progress note for the patient regarding the management of the patient’s diabetes. Include a simple fax cover sheet explaining what you need and why. When these 3 items are faxed back, the shoes and inserts can be dispensed.

Recapping documentation for the DPM Dispense the shoes and complete your note on the fitting and instructions provided. Have your patient sign a proof of delivery form. Beneficiary authorization, instructions, warranty information and return policy information can be included on proof of delivery or forms can be signed separately by patient. Bill CGS using appropriate KX, LT and RT modifiers along with correct amount of units.

WIN-WIN-WIN Protect your patient’s feet Reduce Medicare costs by helping to prevent complications from diabetes Increase office revenue