Part B Insider (Multispecialty) Coding Alert

Published on Fri May 12, 2006 PDF

Question: Our office is about to start a diabetic shoe program. What must we do to become a Durable Medical Equipment Prosthetics, Orthotics and Suppliers (DMEPOS) and what are Medicare’s eligibility requirements for this?


Maryland Subscriber

Answer: The first step is submitting an application to Medicare’s National Supplier Clearinghouse. You will then need to pass a site inspection and comply with a list of supplier standards. Also, your state may require you to obtain a license and comply with local requirements. To check, visit Medicare’s National Supplier Clearinghouse at: www.palmettogba.com.

To participate in the diabetic shoe program, patients must obviously have diabetes mellitus (250.xx), but you don’t need to concern yourself with what type.

Reason: Medicare doesn’t restrict eligibility based on “the severity or type of diabetes, that is to say, juvenile, adult onset, insulin dependent or insulin independent,” says Anthony Poggio, DPM, of Alameda, CA.

You will also need to look at other medical conditions in the patient’s history. Diabetic shoe participants must meet at least one of the following criteria, says Josh White, DPM, CPed, president and medical director of SafeStep in New York City:

1) previous amputation of the foot, or part of either foot (895.0-896.3);
2) history of previous foot ulceration (707.00-707.9);

3) history of preulcerative calluses of either foot (700);

4) peripheral neuropathy with evidence of callus formation (357.2);

5) foot deformity (736.70-736.79);

6) poor circulation (numerous circulatory ICD-9 Codes may apply).

Don’t overlook:  Remember that place of service (POS) is important. If a patient is residing in a skilled nursing facility (SNF) and is in a Part A Medicare stay, the provider of the shoes would need to make arrangements with the SNF for payment, White says. Check with the SNF’s billing office prior to dispensing any DME to its residents, because Medicare does not cover this POS.

If a patient is not a Medicare beneficiary, but still requires diabetic shoes, “you should check with his or her carrier regarding specific coding criteria and claim protocols,” Poggio says.

Some payors, such as Blue Cross Blue Shield of NC, may prefer office POS 11 for DME. Others will stick with Medicare’s requirement to choose the place where the patient will most frequently use the device, such as home.