Got FAQs? June 2020

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By Lisa Lake

Billing for O&P devices and care is complicated. When you have questions, count on Got FAQs? to help keep your claims on track. This month's column answers your questions about the billing criteria for therapeutic shoes and which medical professionals are authorized to write prescriptions for DMEPOS.

Q: I recently graduated and have opened my own O&P facility. I am a pedorthist and have several refer­rals for therapeutic shoes for patients who are diabetic. Can you clarify for me who specifically writes the prescrip­tion for the shoes? What is the criteria for therapeutic shoes to be a covered benefit? How many shoes and inserts can a patient receive every six months or yearly? I appreciate your assistance in helping me make sense out of all of this.

A: According to the Medicare Local Coverage Determination (LCD): Therapeutic Shoes for Persons with Diabetes, the certifying physi­cian is defined as a doctor of medicine (MD) or a doctor of osteopathy (DO) who is responsible for diagnosing and treating the beneficiary's diabetic systemic condition through a com­prehensive plan of care. The certifying physician may not be a podiatrist, phy­sician assistant, nurse practitioner, or clinical nurse specialist.

The prescribing practitioner is the person who writes the order for the therapeutic shoe, modifications, and inserts. This practitioner must be knowledgeable in the fitting of diabetic shoes and inserts. The prescribing practitioner may be a podiatrist, MD, DO, physician assistant, nurse practi­tioner, or clinical nurse specialist. The prescribing practitioner may be the supplier (i.e., the one who furnishes the footwear).

The supplier is the person or entity that furnishes the shoe, modification, and/or insert to the beneficiary and that bills Medicare. The supplier may be a podi­atrist, pedor­thist, orthotist, prosthetist, or other qualified individ­ual. The prescribing practitioner may be the supplier.

Therapeutic shoes and inserts and/ or modifications to therapeutic shoes are covered if all of the following criteria are met: The beneficiary has diabetes mellitus and the certifying physician has documented in the beneficiary's medical record one or more of the following conditions: Previous amputation of the other foot, or part of either foot, or history of previous foot ulceration of either foot, or history of pre-ulcerative calluses of either foot, or peripheral neuropathy with evidence of callus formation of either foot, or foot deformity of either foot, or poor circulation in either foot; and the certifying physician has certified that aforementioned indica­tions one and two are met and that he/ she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes. The certifying physi­cian must have an in-person visit with the beneficiary during which diabe­tes management is addressed within six months prior to delivery of the shoes/inserts, and sign the certifica­tion statement on or after the date of the in-person visit and within three months prior to delivery of the shoes/ inserts. This information can be found at https://go.cms.gov/2WbhBt6.

Q: My colleagues and I have had several discussions about pre­scriptions for braces, whether custom or off-the-shelf, and we have a very expensive lunch riding on your answer. Can a chiropractor write a prescription for any type of brace? What types of prescriptions can a podiatrist write?

A: According to the Medicare Manual, Chapter 3, subject to any limitations posed by the state in which they practice, a doctor of medi­cine; doctor of osteopathy (including osteopathic practitioner) who must be licensed to practice medicine and sur­gery; doctor of podiatry; a physician assistant; nurse practitioner; or a clini­cal nurse specialist may document the medical necessity for orthotics includ­ing completing orders and Certificates of Medical Necessity in place of a phy­sician if the services performed are within their scope of practice as defined by their state, and they are treating the beneficiary for the condition for which the item is needed. Medicare coverage for all items and services furnished or ordered by chiropractors is statutorily excluded.

Therefore, all DMEPOS items ordered by chiropractors are denied. Medicare coverage for all items and services furnished or ordered by podiatrists is limited by state statutes governing the scope of practice for podiatry. You should be familiar with the limitations imposed by the statutes of the state(s) in which you operate and dispense DMEPOS items. To read Chapter 3, visit https://bit.ly/2WB5rIX. 

Lisa Lake is an independent medical consultant with over 25 years of experience in the O&P industry, increasing providers' revenue by product recommen­dation, product and billing knowledge, and contract access assistance. She is a nationally recognized speaker on billing reimbursement and government compliancy. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. Lake can be contacted at llakeusa@gmail.com.