Podiatry Coding & Billing Alert

Remember: The diabetic shoe benefit resets itself every calendar year.

From understanding the one calendar year coverage requirement, to mastering certain policy-specific requirements outlined in the local coverage determination (LCD) L33369 and Policy Article A52501, there are many details you need to remember when dealing with diabetic shoe claims.

Take following quiz to make sure you don't miss a step and always submit clean diabetic shoe claims.

Grasp The One Calendar Year Coverage Requirement

Question 1: What is the timeline for the coverage criteria of diabetic shoes?

Answer 1: Diabetic shoe coverage is valid for one calendar year, said Michael Hanna, MPA, CDME, provider relations senior analyst at CGS-DME MAC Jurisdiction C in Nashville, Tennesse, in a recent "A/B-DME Collaborative Diabetic Shoes" webinar.

The benefit resets itself every year. So, in January 1, 2018, every patient who requires diabetic shoes is eligible for diabetic shoes, Hanna says. It doesn't matter when in 2017 the patient received his pair of shoes.

"We've seen instances where the patient will get shoes in December of one calendar year - if he hasn't had any shoes in the entire year," Hanna says. "Then he can get another pair in January. That is acceptable."

If a patient meets the coverage criteria for diabetic shoes, he may receive one of the following during the calendar year:

• 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) and two additional pairs of inserts - A5512 (For diabetics only, multiple density insert, direct formed, molded to foot ...) or A5513 (For diabetics only, multiple density insert, custom molded from model of patient's foot...); or
• 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 (A5512 or A5513). Note: These three pairs of inserts do not include the non-customized, removable inserts provided with the shoes.

The type of shoe the patient will receive depends on his foot problems and abnormalities, Hanna says. For example, if the prescribing physician feels like the A5500 versus the A5501 will better fit the patient's needs or vice versa, per year.

Familiarize Yourself With The Standard Documentation Requirements

Question 2: What are the standard documentation requirements for diabetic shoes?

Answer 2: The following requirements are standard and applicable across every durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item ordered, according to Hanna:

• Medical records
• Dispensing order
• A detailed written order must be in the supplier's possession before he can file a claim to Medicare
• Correct coding
• That particular supplier filing the claim must have proof of delivery documentation and keep it on file for seven years.

Keep Policy-Specific Documentation Requirements in Mind

Question 3: What are some policy-specific documentation requirements for diabetic shoes?

Answer 3: From this particular L33369 and policy article A52501, there are certain documentation requirements, according to Hanna. They are as follows:

• The certifying physician statement - the template or statement is applicable to diabetic shoes
• There must be a qualifying foot exam 
• In-person foot evaluation before the shoes are ordered
• Fit evaluation at delivery.

Make Sure the Dispensing Order Includes These Details

Question 4: What is a dispensing order?

Answer 4: The shoes and inserts may be delivered to the patient upon receipt of a dispensing order, Hanna says.

However, you should note that the dispensing order depends on how the transaction is set up, according to Hanna.

For example, if the podiatrist does the foot exam, orders the shoes, and takes care of them in his office, there won't be a dispensing order because he will just create the order.

However, if the primary care physician takes care of the patient's diabetic management, and the podiatrist does the foot exam, but that particular office doesn't provide shoes, they will go to the supplier for the shoes, Hanna shoes. The supplier would then provide the shoes based on the dispensing order.

The dispensing order must include the following information, according to Hanna:

• The patient's name
• The ordering physician's name
• Description of the item(s)  provided
• The order date
• The physician's signature or the supplier's signature.

Always Include This Info in a Detailed Written Order

Question 5: What information should the provider include in the detailed written order?

Answer 5: A detailed written order for diabetic shoes should include the following information:

• The patient's name
• The order date
• Detailed description of the items provided
• The physician's signature and signature date.

Although it's acceptable for someone other than the prescribing physician to complete the detailed written order, but the prescribing physician must sign it and date it, Hanna says.

Know When You Need a New Order

Question 6: When does the provider need to create a new written order?

Answer 6: A new order is required if there is a replacement of any shoe, or a replacement of an insert or modification more than one year from the most recent order on file, Hanna says.

Note: If the beneficiary is involved in an unfortunate situation like a flood or house fire, Medicare will replace the shoes, according to Hanna. There would just need to be a new order created.