Therapeutic Shoes for Persons with Diabetes Activity Timeline Tool

The tool will help determine if the dates of service, in-person visit, Certification Statement and documentation from another provider when the in-person visit is with a podiatrist, other 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, and that documents one or more of criteria a-f, is within the timelines identified in the Local Coverage Determination (LCD) or Policy Article for TSPD.

Note: Enter dates in the format of (mm/dd/yyyy)

Is the Documentation for Criteria 2 a-f contained within:

The Face-to-Face Visit with the Certifying Provider Documentation
The Face-to-Face Visit with Another Provider Documentation

Date of the Face-to-Face Visit with Another Provider:

Date of the Agreement with Another Provider:

Date of the Face-to-Face Visit with the Certifying Provider:

Date the Certification Statement was Signed:

Date of Service (DOS):

Last Updated Feb 14 , 2024

DME Jurisdiction D

Therapeutic Shoes for Persons with Diabetes Activity Timeline Tool - JD DME

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Therapeutic Shoes for Persons with Diabetes Activity Timeline Tool