Is Offering Diabetic Shoes a Good Fit for Your Practice?

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By Séamus Kennedy, BEng (Mech), CPed

"I have diabetes, but why should I wear special shoes?
Why can't I just buy my shoes from a local department store like everyone else?"

LEAP monofilament test.
LEAP monofilament test.

Sound familiar? For many practitioners treating patients with diabetes, these are common patient sentiments-spoken or unspoken. Of the more than 14 million Americans who have been diagnosed with diabetes, about 25 percent will develop foot problems related to the disease. These foot problems often develop from a combination of causes, including poor circulation (which impairs the healing process) and lack of sensation to pain, heat, or cold. With lack of feeling in their feet, persons with diabetes can develop minor cuts, blisters, or pressure sores and not be aware that a wound is developing. If these minor injuries are not noticed and are left untreated, serious complications like skin ulcerations may arise and could eventually lead to the need for amputation.

Good for Business, Good for Patients

Many in the O&P industry would probably prefer not to focus on shoes in their practice. However, there are a number of reasons to consider adding this niche to your practice. The majority of practitioners who do provide this valuable service tell me that they do so in order to please all of their important referral sources. Indeed, many clinics and orthopedists will insist that in addition to regular O&P services, orthotists include extra-depth and custom-shoe fitting. This allows a practice to build a larger patient following of targeted consumers. Considering that the numbers of both those diagnosed with diabetes and Medicare recipients are expected to swell in the coming years, this can spell quite a business opportunity.

Chukka boot with toe filler and removable insole.
Chukka boot with toe filler and removable insole.

Adding this service to your practice can also go a long way to enhancing diabetic patient care. People with diabetes are advised to inspect their feet daily to watch for potential problems because it is important that they prevent all foot-related injuries. One of the best ways to do this is to wear proper-fitting and correctly constructed shoes. Wearing tight-fitting or inappropriate shoes greatly increases the chances that a serious foot complication will develop.

The development of any peripheral neuropathy in a patient is a cause for grave concern regarding his/her footwear. Diabetic neuropathy is directly related to the length of time that nerve fibers are exposed to hyperglycemia. Elevated blood glucose levels will, over time, decrease nerve function. Loss of function such as weakness or decreased feeling, and symptoms of prickling, tingling, or pain may occur together. Diminished sensation increases the potential for skin damage. Loss of feeling usually starts at the extremities (distal neuropathy), in the hands and feet, so particular attention needs to be paid to any wounds or lesions that may develop there.

[ Editor's note: For more information about neuropathy, see" Stepping Out ," The O&P EDGE , October 2006.]

Professional Fit, Fewer Complications

There are two common misconceptions regarding shoe fit: (1) patients know their shoe size; and (2) patients can feel when a shoe is right for them. Unfortunately, many people with diabetes have poor feeling in their feet, so they may be inclined to purchase shoes that are too tight and too small. This can lead to serious complications. If patients with diabetes have any loss of sensation in their feet, they should have their shoes fitted by a pedorthist, orthotist, podiatrist, or other qualified professional. A pedorthist will be able to measure their feet correctly and choose a shoe with the correct last shape appropriate for their foot type. Good, protective shoes will typically have soft lining materials and an absence of seams at critical locations inside the shoe.

As the professional, you need to measure both of their feet. Often shoe sizes change as people get older or heavier (like most of us). Shoe fit also depends on the last model used to make the actual shoe shape. The pedorthist will know the best shape for a particular foot.

Raising Awareness

In the late 1980s, the federal government began to recognize the increased incidence of foot amputations in people with diabetes. As a result, they developed the Medicare Therapeutic Shoe Bill (TSB) to provide protective footwear and insoles for people with diabetes who are at-risk for amputations.

Part of the increase in awareness resulted in the Lower Extremity Amputation Prevention (LEAP) program. This is a comprehensive foot screening program developed in conjunction with the Hansen's Disease Center, in Carville, Louisiana. [Editor's note: For more information visit  www.hrsa.gov/leap] There is a simple and quick diagnostic tool that can quickly indicate the level and progression of neuropathy in a foot. The test usually consists of strands of monofilament that are gently applied; i.e., prodded onto the plantar surface of the foot until the filament bends. If the patient cannot sense the thinnest filament after it has bent, then neuropathy is present. The thicker the filament required to register sensation, the more advanced the nerve degeneration.

Foot Care Doesn't Stop After Amputation

As the diabetic condition progresses, sometimes, in spite of best efforts by all, an amputation is necessary. Pedorthists and orthotists can help partial-foot amputees in the following ways:

  1. Select the appropriate footwear that properly fits and supports the remainder of the foot.
  2. Design a toe filler that mimics the shape of the old foot. This filler can be incorporated into the shoe as part of a custom foot orthotic so that the foot will appear normal from the outside and so that the shoe's toe box will not collapse. Partial foot amputation toe fillers can be billed under the L-5000 code; these are usually considered an addition to the regular billing of the TSB.
  3. Add rocker soles, wide flares, or wedges to many shoes to help improve a partial amputee's gait and stability.
  4. Custom-molded shoes may be needed for the worst cases where a patient's feet are so deformed, edemous, or mismatched that not even an extra-depth orthopedic shoe will accommodate one or both feet. The further complication of Charcot breakdown or the need for any type of AFO frequently requires that custom shoes be considered. Anecdotally, it appears that 5-10 percent of the qualifying diabetic population requires some form of custom footwear.

Although some of these options may appear expensive, the expense is relative. People with diabetes and who are at risk for ulcers and amputations must protect their feet at all costs. Allowing an infection to begin can have dire consequences to a patient's long-term health. Not every diabetic patient needs custom shoes and custom orthotics, but they should all have proper-fitting and functioning footwear. Offering diabetic shoes in your practice can be an attractive draw for patients and referral sources.

Séamus Kennedy, BEng (Mech), CPed, is president and co-owner of Hersco Ortho Labs, New York City. He can be contacted via e-mail at  seamus@hersco.com, or visit  www.hersco.com

The Medicare Therapeutic Shoe Bill: A Synopsis

The Medicare Therapeutic Shoe Bill (TSB) 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.

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). 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.

As a qualified individual, you may then provide the footwear. As a supplier, you need to have a National Supplier Clearinghouse (NSC) number in addition to your Medicare National Provider Identifier (NPI) 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 claim to indicate that you have an up-to-date prescription and "Statement of Certifying Physician" on file.

More recently, standards have been set regarding the quality and construction of all insoles for the TSB (see Codes A-5512 and A-5513). The manufacturers and fabricators are now required to have a letter of statistical analysis durable medical equipment regional carrier (SADMERC) approval in order for their product to be billed under these codes.

This is a general outline of the TSB. For detailed information about coding, billing, and shoe choices, visit www.safestep.net and www.surefitlab.com. For the most current coding information, visit www.cms.hhs.gov/home/medicare.asp , then click on "Coding," and "HCPCS Release and Code Sets."