Therapeutic Shoes for Persons with Diabetes

Coverage

Documentation

Reviews/Audits

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

Practitioner Activity Timeline

Activity Practitioner Requirements
Visit to document diabetes mellitus management Certifying MD/DO, NP/PA "incident to", NP PCF Demonstration Project Within 6 months prior to delivery
Visit to document qualifying foot condition Certifying MD/DO, other MD/DO, Podiatrist, PA, NP, CNS Within 6 months prior to delivery
Complete the Certification Statement Certifying MD/DO, NP/PA "incident to" supervising MD/DO must verify (sign/date), NP PCF Demonstration Project
  • Within 3 months prior to delivery
  • Signed on or after visit(s) to document diabetes management and foot condition
Sign the SWO Treating Practitioner: Certifying MD/DO, other MD/DO, Podiatrist, PA, NP, CNS After visit with the treating practitioner

 

Supplier Activity Timeline

Activity Supplier Requirements
Selection Visit Supplier Prior to selecting the specific items that will be provided
Fit Assessment/Delivery Visit Supplier After selection visit
Claim Submission Supplier
  • After delivery
  • After receiving SWO
  • After receiving certification statement

 

NP or PA as Certifying Physician

NP Participant of PCF Model Demonstration Project NP or PA Practicing "incident to" Certifying Physician
Acts as certifying physician Acts as certifying physician
Performs exam Performs exam
Documents in medical record Documents in medical record, supervising physician signs, dates and indicates agreement
Completes certification statement Completes certification statement, supervising physician co-signs

 

Tips

Topic Details
Criteria 2
  • To meet criterion 2, certifying physician (MD/DO, NP/PA practicing "incident to", NP part of PCF Demonstration Project) must either:
    • Personally document one or more of criteria 2a-2f in medical record if they have performed foot exam and prescribed shoes; or
    • MD/DO - 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 MD or D.O., physician assistant, nurse practitioner, or clinical nurse specialist, practicing independently, 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
    • NP/PA practicing "incident to" - Documents in medical record, then supervising physician signs, dates and indicates agreement. NP/PA completes certification statement. Supervising physician co-signs
    • NP part of PCF Demonstration Project - Documents in medical record and completes certification statement
  • 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 the certifying physician can provide order for shoes and do foot exam but MD/DO or NP/PA as certifying physician must be treating beneficiary for their diabetic condition. The beneficiary must be seen within six months prior to delivery of shoes. This requirement is the 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. For all shoes, taking measurements of the beneficiary’s feet is also required each year
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

Medicare Coverage for Shoes - Correct Coding - Revised

Therapeutic Shoes vs Orthopedic Footwear

Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. In order to be eligible for coverage, such items must qualify in either:

  1. the benefit category for therapeutic shoes provisioned in the treatment of a diabetes-related condition(s) or
  2. the benefit category for leg braces (to which the shoes and related items would be considered for coverage as integral components of the leg brace).

Therapeutic Shoes vs Orthopedic Footwear -

Shoes, inserts, shoe transfer, modifications covered in limited circumstances

  • Coverage includes select diabetic beneficiaries
  • Orthopedic shoes covered if integral part of covered leg brace
    • Search applicable brace codes in Orthopedic Footwear Policy Article A52481
    • Shoes incorporated into a brace must be billed by same supplier billing for brace
      • When initially providing brace
    • Shoes billed separately (i.e., not as part of brace) deny noncovered
  • Shoes/related modifications, inserts, heel/sole replacements, shoe transfers
    • Only covered when shoe is integral part of covered leg brace
    • Must be medically necessary for proper functioning of brace
    • Must be billed with KX modifier or will deny noncovered, statutorily excluded
  • Shoe Transfers to beneficiary owned item
    • All suppliers are allowed to provide replacement shoes or braces when the shoe is an integral part of a covered leg brace. When billing the transfer, follow the orthopedic footwear policy article for shoe transfers. A KX modifier must be added to the code. An order is not required for the transfer of a shoe to a brace
Nurse Practitioners and Physician Assistants as Certifying Physicians for Therapeutic Shoes and Inserts
Partial Foot, Shoe Insert (Toe Fillers), and Shoe Inserts for Diabetics - Coding Based on Benefit Category - Correct Coding Guidance for billing Partial Foot, Shoe Insert (Toe Fillers) , and Shoe Inserts for Diabetics
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.
RT/LT Modifiers
  • 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

 

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.

 

Last Updated Feb 20 , 2024

Related Articles

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Articles Source Posted
Primary Care First Model Demonstration Project 07/18/2023
Therapeutic Shoes for Persons With Diabetes (TSPD) Certifying Physician 02/15/2023
Policy Article Revisions Summary for July 7, 2022 07/07/2022
See How Nurse Practitioners (NP) and Physician Assistants (PA) Qualify as Certifying Physicians for Therapeutic Shoes and Inserts 03/21/2022