Updating the Medicare Shoe Bill

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By Seamus Kennedy, BEng (Mech), CPed

During the past year the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) and Durable Medical Equipment Regional Carriers (DMERCs) have been busy overhauling portions of the Therapeutic Shoe Bill. These most recent changes to the bill focus on the quality of the inserts being provided. The new K- Codes for the inserts specify a firmer base material and an overall greater thickness.

The Medicare Therapeutic Shoe Bill was enacted by Congress in order to provide proper footwear and inserts for people with diabetes who qualify under Medicare Part B. The program was designed to prevent lower limb ulcers, amputations, and other complications in people who suffer from the disease. Eligible patients qualify for one pair of shoes, plus extra pairs of inserts and/or shoe modifications for each calendar year.

Many of the extra-depth and custom-molded shoe companies have designed specific programs to meet this bill, which ensure that the patient gets excellent foot protection and that you can still make a fair profit. Medicare will reimburse for 80 percent of the amount allowed, and the patient is responsible for a minimum of 20 percent. The billing codes and allowables for this program are listed in Table 1 at the end of this article.

In order to qualify for the program, certain criteria must be met. First, the doctor--an MD or DO-- treating the diabetes must fill out the "Statement of Certifying Physician" (see Table 2 at end of article). A copy of this certificate must be kept in the patient's chart. Second, you need a prescription for the necessary footwear from the doctor who is treating the foot condition .

You, as a qualified individual, may then provide the footwear. As a supplier, you need to have a National Supplier Number in addition to your Medicare provider number. New paperwork and prescriptions are required for the replacement of shoes or inserts. It is also important to note that a "KX" modifier should be used on your claims to indicate that you have an up-to-date prescription and Statement of Certifying Physician on file.

This is a general outline of the Therapeutic Shoe Bill. There are several websites that offer more specific information on the coding, billing, and shoe choices. Two good examples of sites where you can obtain more details are: www.safestep.net and www.surefitlab.com .

Billing Codes for Use Under
The Medicare Therapeutic Shoe Bill

CODES

DEFINITION

ALLOWABLE*

A5500

For diabetics only, fitting, preparation, and supply of the off-the-shelf depth inlay shoe manufactured to accommodate multi-density inserts, per shoe. Note: These shoes must have a removable filler or insole that extends from heel to toe and provides at least 1/4" of additional depth when removed. This space is needed to accommodate a multi-density insert, K0628 or K0629. The upper must be made of leather or other suitable material of equal quality. The shoe must have some form of closure such as laces or Velcro. The shoe must be available in a range of full and half sizes and at least three widths to assure proper fit.

$66.00/shoe ($132.00/pair)

A5501

For diabetics only, fitting, custom preparation, and supply of shoe-molded from cast(s) of patient's foot (custom molded shoe), per shoe. Note: A custom shoe is only covered when a patient has a foot deformity which cannot be accommodated by a depth inlay shoe. This deformity must be documented in the suppliers records in case Medicare wishes to review these records to verify that the patient could not have been fit with the less expensive depth inlay shoe, A5500.

$198.00/shoe ($396.00/pair)

K0628

For diabetics only, multiple density insert, direct formed, molded to foot after external heat source (greater than or equal to 230° F ) total contact with patient's foot, including arch, base layer minimum of 1/4" material of Shore A 35 durometer, or 3/16" material of greater than or equal to Shore A 40 durometer, prefabricated, each.

$33.50/shoe ($67.00/pair)

K0629

For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16" material of greater than or equal to Shore A 35 durometer, includes arch filler and other shaping material, custom fabricated, each.

$33.50/shoe ($67.00/pair)

A5503

For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe.

$33.50/shoe ($67.00/pair)

A5504

For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoe or custom molded shoe with wedges, per shoe.

$33.50/shoe ($67.00/pair)

A5505

For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoes or custom molded shoe with metatarsal bar, per shoe.

$33.50/shoe ($67.00/pair)

A5506

For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoe or custom molded shoe with off-set heel, per shoe.

$33.50/shoe ($67.00/pair)

A5507

For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth inlay shoe or custom molded shoe, per shoe. Note: When you use this code, a narrative description of the modification or feature must be contained on the claim.

$33.50/shoe ($67.00/pair)

*Prices may vary slightly depending on your state. These prices are the maximums established by Congress. Contact your Durable Medical Equipment Regional Center (DMERC) for more details.

Table 1.


Table 2.
Table 2.