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Therapeutic Shoes for Persons with Diabetes

The Standard Written Order (SWO) requirements are in effect for dates of service January 1, 2020 and after.
Refer to the SWO page for the elements needed in this streamlined order.

Coverage

Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Tips

Topic Details
Criteria 2
  • To meet criterion 2, certifying physician (must be MD or DO) must either:
    • Personally, document one or more of criteria 2a–2f in medical record if they have performed foot exam and prescribed shoes; or
    • Obtain, initial, date/sign (prior to or on same day as signing certification statement), and indicate agreement (I agree) with information from medical records of an exam and order from a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that documents one of more of criteria 2a–2f. It is not specific as to where agreement exists but must be included on actual medical record
  • Some foot deformity examples include bunions and hammertoes but are not limited to these
Criteria 3
  • Certifying physician is not required to document a foot exam and/or need for diabetic shoes in his/her medical record when they are NOT prescribing physician. If provider who prescribed shoes has documented one or more of conditions 2A-2F and certifying physician has dated/initialed and indicated agreement with those records prior to signing Certification Statement, criteria 2 will be met. Records are not required to match if Certifying Physician has agreed with records of provider who prescribed shoes and performed foot exam
  • When suppliers are reviewing physician's medical records for a comprehensive plan of care, physician must have documented in those notes what is occurring with beneficiary's diabetes and how are they managing their diabetes. This will be different for every beneficiary and their condition. May include adjusting medications/monitoring their diet/exercise regimen/reviewing their blood sugar logs or getting labs like A1C
  • A provider other than a MD or DO can provide order for shoes and do foot exam with Certifying Physician dating, initialing and indicating agreement with those records but MD or DO must be treating beneficiary for their diabetic condition and they must be seen within six months prior to delivery of shoes. This requirement is same whether suppliers are in a rural area or not
Criteria 4
  • When custom molded inserts are provided by suppliers, suppliers must conduct and document taking impressions, making casts or obtaining CAD-CAM images of feet. This must be conducted each year beneficiary is receiving shoes
Criteria 5
  • To meet criterion five, at time of in-person delivery to beneficiary of items selected, supplier must conduct an objective assessment of fit of shoe and inserts and document results. This is to verify that shoes/inserts properly fit beneficiary. A beneficiary's subjective statements regarding fit as sole documentation of in-person delivery does not meet this criterion. Some examples of what would be in "fitting" chart note for an objective assessment will include quantifying data. There should be objective information about what fitter observed. E.g., foot box fits properly, length and width are appropriate, beneficiary walked a few steps and there was no rubbing, etc. It is not a requirement that beneficiary ambulate while wearing shoes
Nurse Practitioners and Physician Assistants as Certifying Physicians for Therapeutic Shoes and Inserts
RT/LT Modifiers
  • Effective for claims with dates of service (DOS) on or after 3/1/2019, suppliers must bill each item on two separate claim lines using the RT and LT modifiers and 1 UOS on each claim line. Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single claim line, will be rejected as incorrect coding
Primary Care First Model Demonstration Project - Nurse Practitioners as Certifying Physicians for Therapeutic Shoes and Inserts
  • CMS is exercising its authority under the Primary Care First (PCF) model to waive Section 1861(s)(12) of the Act and the implementing regulations at 42 CFR 410.12 to allow nurse practitioners to certify that an order for diabetic shoes is required according to Section 1861(s)(12). Additional information, including the PCF Participant list and the Participating Regions and Payer Partners, are at the bottom of the PCF model page.

 

Resources

  • Clarification of Criterion 5 - Per the LCD, "The in-person evaluation of the beneficiary by the supplier at the time of delivery…must be conducted with the beneficiary wearing the shoes and inserts and must document that the shoes/inserts/modifications fit properly."
  • PDAC Coding Guidelines for Off-the-Shelf Diabetic Shoes (A5500) - The information presented in this article comes from the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (L33369) and related Policy Article (A52501), coding language, coding guidelines, and assessment of samples that have been submitted to the PDAC for Code Verification Review.
  • Toe Fillers and Diabetic Shoe Inserts - Shoe inserts for beneficiaries with missing toes or partial foot amputations who are not diabetic are considered for coverage under the prosthetic benefit
     

Last Updated Tue, 10 Aug 2021 15:15:53 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

paginationType noridian
Therapeutic Shoes Targeted Probe and Educate Review Updates: April-June 2019 10/22/2019