Podiatry Coding & Billing Alert

Remember: Certifying physician must be M.D. or D.O.

Reporting diabetic shoes can be tricky because you have to meet numerous criteria or Medicare will deny your claim. Not only do you have to learn the roles of the certifying physician, supplier, and prescribing provider, but you also must know what must happen during the diabetic foot exam and the supplier’s evaluation.

Shatter the following myths to ensure that you never leave money on the table when billing for diabetic shoes.

Myth 1: Diabetes Dx Not Needed to Receive Shoes

Reality: The patient must have diabetes, according to Michael Hanna, MPA, CDME, provider relations senior analyst at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar. The diabetic shoe policy is diagnosis-driven, and there is a list of applicable diabetic diagnoses that must be on your claim.

If you file a claim for diabetic shoes and the beneficiary does not have diabetes, Medicare will deny your claim based upon medical necessity, Hanna explains.

Don’t forget: The LCD identifies a lengthy list of covered ICD-10 codes, which includes E08.00 (Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma [NKHHC]) through E13.9 (Other specified diabetes mellitus without complications).

Myth 2: Not Necessary for Certifying Physician to Document Diabetes Management

Reality: The certifying physician, the M.D. or D.O. responsible for diagnosing and treating the patient’s diabetes, must document that he is treating and managing the patient’s diabetic systemic condition by a comprehensive plan of care that supports the ICD-10 code you report on the diabetic shoe claim, according to Hanna.

Important: It is not appropriate for the patient to go and see a nurse practitioner, for example, then for the M.D. to come along and simply co-sign the medical record, Hannan explains. The M.D. or D.O must conduct the encounter where he discusses the patient’s diabetic condition with her.

Myth 3: Only Certifying Physician Can Perform Foot Exam

Reality: As a requirement to receive diabetic shoes, the diabetic patient must undergo a foot exam. Although the certifying physician can perform the exam, this is not your only option, according to Hanna.

Another medical professional such as a podiatrist, other M.D. or D.O., physician assistant, nurse practitioner, or clinical nurse specialist can conduct the patient’s foot exam, then send it back to the certifying physician, Hanna explains. The certifying physician will then review the medical record, initial and date it, and send it back to the practitioner or physician who conducted the foot exam.

Example: The certifying physician, Dr. Monroe, manages Mr. Smith’s diabetic systemic condition. Dr. Monroe believes that Mr. Smith would benefit from a pair of diabetic shoes, so he refers Mr. Smith to a podiatrist, Dr. Taylor. Dr. Taylor performs Mr. Smith’s foot exam, then sends the medical record back to Dr. Monroe, who reviews the results, initials and dates the medical record, and sends it back to Dr. Taylor.

Myth 4: Specific Conditions Don’t Have to be Documented During Exam

Reality: Either the certifying physician or the practitioner who conducts the foot exam must document one of more of the following conditions in the patient’s medical record, Hanna explains:

• Previous amputation of the other foot, or part of either foot
• History of previous foot ulceration on either foot
• History of pre-ulcerative calluses of either foot
• Peripheral neuropathy with evidence of callus formation of either foot
• Foot deformity of either foot. You must include a detailed description of the deformity.
• Poor circulation in either foot. There must be documented, detailed evidence of poor circulation, according to Hanna. Simply a statement saying the patient has deformed feet is not enough.

Important: The above conditions must be documented during an in-person visit within six months prior to the delivery of the shoes and/or inserts and prior to or on the same day as signing the certification statement.

Myth 5: Statement of Certifying Physician not Required

Reality: The certifying physician must complete, sign, and date a statement where he indicates that the diabetic systemic condition is met, he is treating the patient for the diabetic condition, and the patient needs diabetic shoes, Hanna explains.

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

Myth 6: Supplier Evaluation not Important Requirement

Reality: Before he orders diabetic shoes for the patient, the supplier must conduct and document an in-person evaluation of the patient’s feet, Hanna explains. This is a necessary criteria for diabetic shoes.

During this evaluation, the supplier should document measurements of the patient’s feet, along with the description of abnormalities the shoes/inserts/modifications will accommodate.

Myth 7: In-Person Delivery of Shoes Unnecessary

Reality: The diabetic shoe and/or insert delivery must be conducted in-person, Hanna says. You should never ship diabetic shoes to the patient. This must be an in-person delivery where the patient comes in to ensure that the fit is correct.

Also, at the time of the in-person delivery, the supplier must conduct an objective assessment of the fit of the shoe and/or inserts, and he must document the results. During this assessment, the supplier must document objective information about the fit and how the shoes will accommodate the patient’s foot problems.

Caution: A patient’s subjective statement regarding the fit of the shoe as the sole documentation of the in-person delivery does not meet this requirement, Hanna says.

“We’ve seen examples where the patient says, ‘The shoes fit well, or I like the color,’ but these statements are not enough,” Hanna explains. “Instead, we need the supplier to assess the fit and document information such as how the extra-depth shoe or the wide toe box or the particular custom insert accomadates the foot problems the medical professional found when he performed the foot exam.”

Important: The supplier’s evaluation must be made while the patient is wearing the diabetic shoes and inserts.