CERT and Therapeutic Shoes for Persons with Diabetes - Dear Physician Letter - JA DME

April 2014

Dear Physician,

The Comprehensive Error Rate Testing (CERT) Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), performs medical review audits for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provided to Medicare beneficiaries to determine the paid claims error rate for Medicare contractors and providers.

Medicare covers therapeutic shoes and inserts for persons with diabetes as established by the Social Security Act Section 1861(s) (12). You may access the Therapeutic Shoes for Persons with Diabetes (TSPD) LCD and Related Policy Article on the CMS website under the Medicare Coverage Database. In order for your patient to qualify for these shoes and inserts, Medicare statute mandates specific coverage and documentation requirements that must be met.

The most common CERT errors center on missing documentation from the certifying physician of the patient having diabetes, the existence of one or more of the conditions for coverage and the therapeutic plan of care. Three criteria are critical to coverage and form the majority of physician-related CERT errors:

1. Documenting your management of the beneficiary's diabetes. You are considered the "Certifying Physician" and there is no substitute for this documentation requirement. The Certifying Physician, by statute, must be an M.D. or D.O. and not a nurse practitioner, physician assistant or clinical nurse specialist;
2. Documenting a qualifying foot condition. As opposed to the criteria above regarding documentation of the beneficiary's diabetes management, the documentation of the qualifying foot condition may come from your records or by your indication of agreement (signified by initialing and dating) with information from the medical records of an in-person visit with a podiatrist, another M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts.
3. Failure of the records to substantiate that an in-person visit occurred within 6 months prior to the delivery of the shoes or inserts.

It is important to note that even though you may complete and sign a form attesting that all of the coverage requirements from the policy have been met, there also must be documentation in your records to indicate that you are managing the patient's diabetes and records from either your chart or that of another practitioner documenting a qualifying foot condition.

Please refer to the Local Coverage Determination (LCD) on Therapeutic Shoes for Persons with Diabetes (TSPD), the related Policy Article and the Supplier Manual for additional information about coverage, billing and documentation requirements. Thank you for your assistance in reducing the CERT error rate.

Sincerely,

Paul J. Hughes, M.D.
Medical Director, DME MAC, Jurisdiction A
NHIC, Corp.

Stacey V. Brennan, M.D., FAAFP
Medical Director, DME MAC, Jurisdiction B
National Government Services

Robert D. Hoover, Jr., MD, MPH, FACP
Medical Director, DME MAC, Jurisdiction C
CGS Administrators, LLC

Eileen M. Moynihan, MD, FACP, FACR
Medical Director, DME MAC, Jurisdiction D
Noridian Healthcare Solutions