Podiatry Coding & Billing Alert

Don’t miss: The certifying physician can only be an M.D. or a D.O.

Navigating diabetic shoe claims can become really complicated if you don’t understand the myriad of roles involved in the process — certifying physician, supplier, and prescribing provider. You must know exactly what these individuals can and cannot do when it comes to patients receiving diabetic shoes, if you want to submit clean claims.

Read on to learn more.

Myth 1: Certifying Physician Can be any Type of Provider

Reality: The certifying physician can only be an M.D. or a D.O., according to Michael Hanna, MPA, CDME, provider relations senior analyst at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar. No other medical professional can be the certifying physician. This includes podiatrists, physician assistants, nurse practitioners, or clinical nurse specialists.

The certifying physician is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care, Hanna explains. The certifying physician must have an in-person visit with the patient where they discuss diabetes management within six months prior to the delivery of the patient’s shoes and/or inserts.

Important: “The certifying physician must sign the certification statement on or after the date of the in-person visit and within three months prior to the delivery of the shoes/inserts,” Hanna adds.

Myth 2: Prescribing Practitioner Cannot be Supplier

Reality: The prescribing practitioner may be the DME supplier — the one who furnishes the footwear, according to Hanna. We see this pretty frequently because many podiatrists’ offices may conduct the foot exam, write the order for the shoes, and then have the patient come back in at delivery and make sure the fit is correct.

Prescribing practitioner defined: The prescribing practitioner writes the order for the therapeutic shoe, modifications, and inserts, according to Hanna. This practitioner must be knowledgeable in the fitting of diabetic shoes and inserts.

Unlike the certifying physician, the prescribing practitioner can be another medical professional such as a podiatrist, M.D., D.O., physician assistant, nurse practitioner, or clinical nurse specialist, Hanna adds. Also, the certifying physician may be the prescribing physician.

Important: There must be an in-person visit with the prescribing practitioner within six months prior to the delivery of the shoes and/or inserts.

Myth 3: DME Supplier Cannot Be Podiatrist

Reality: The supplier may be a podiatrist, orthotist, prosthetist or other qualified individual, Hanna explains. The supplier is the person or entity who furnishes the shoe, modification, and/or insert for the patient and who bills Medicare.

The prescribing practitioner may be the supplier, according to Hanna. However, the certifying physician can only be the supplier if the certifying physician is practicing in a defined rural area or a defined health professional shortage area.

The supplier must conduct and document an in-person evaluation of the patient prior to selecting the specific items he will provide, Hanna explains. Then, at the time of the in-person delivery, the supplier will conduct an objective assessment of the fit of the shoe and inserts and document the results.