<img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2005-03_07/KennedySeamus.jpg" hspace="4" vspace="4" /> The Centers for Medicare & Medicaid Services (CMS) has announced new reimbursement rates for the Therapeutic Shoe Bill effective in 2005. The Medicare Prescription Drug Improvement and Modernization Act, enacted in December 2003, required that CMS begin to devise the new payment rates. Rates had originally been set by Congress in the late 1980s. There was general disappointment within the industry that the rates were lowered between 10-20 percent. This is especially the case since it felt that the TSB has been successful in meeting its original objectives: preventing lower-limb ulcers, amputations, and other complications in people suffering from diabetes. The one code that did receive an increase was K-0629: custom-molded inserts. This reflects a growing focus on the quality of the inserts dispensed. This is the third time in as many years that the custom insert code has been modified. 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. Eligible patients qualify for one pair of shoes, plus extra pairs of inserts and/or shoe modifications for each calendar year. Medicare will reimburse 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 <b>Table 1</b> . <table border="1" width="525" cellspacing="0" cellpadding="10"> <tbody> <tr> <td colspan="3" align="center" valign="middle" bgcolor="#000000"><span style="color: #ffffff; font-family: Verdana;"><span style="color: #ffffff; font-family: Verdana;"> Billing Codes for Use Under</span></span>The Medicare Therapeutic Shoe Bill</td> </tr> <tr> <td align="center" width="50">CODES</td> <td align="center" width="300">DEFINITION</td> <td align="center" width="175">ALLOWABLE*</td> </tr> <tr> <td valign="top">A5500</td> <td>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.</td> <td align="center" valign="top">$59.36/shoe ($118.72/pair)</td> </tr> <tr> <td valign="top">A5501</td> <td>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 supplier's 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.</td> <td align="center" valign="top">$178.04/shoe ($356.08/pair)</td> </tr> <tr> <td valign="top">K0628</td> <td>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.</td> <td align="center" valign="top">$24.22/shoe ($48.44/pair)</td> </tr> <tr> <td valign="top">K0629</td> <td>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.</td> <td align="center" valign="top">$36.14/shoe ($72.28/pair)</td> </tr> <tr> <td valign="top">A5503</td> <td>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.</td> <td align="center" valign="top">$26.40/shoe ($52.80/pair)</td> </tr> <tr> <td valign="top">A5504</td> <td>For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoe or custom molded shoe with wedges, per shoe.</td> <td align="center" valign="top">$26.40/shoe ($52.80/pair)</td> </tr> <tr> <td valign="top">A5505</td> <td>For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoes or custom molded shoe with metatarsal bar, per shoe.</td> <td align="center" valign="top">$26.40/shoe ($52.80/pair)</td> </tr> <tr> <td valign="top">A5506</td> <td>For diabetics only, modification (including fitting) of off-the-shelf depth inlay shoe or custom molded shoe with off-set heel, per shoe.</td> <td align="center" valign="top">$26.40/shoe ($52.80/pair)</td> </tr> <tr> <td valign="top">A5507</td> <td>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.</td> <td align="center" valign="top">$26.40/shoe ($52.80/pair)</td> </tr> <tr> <td colspan="3" align="center">*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.</td> </tr> </tbody> </table> Table 1. In order to qualify for the program, certain criteria must be met. First, the doctor--an MD or DO-- <b>treating the diabetes </b>must fill out the "Statement of Certifying Physician." (See <b>Table 2</b>). A copy of this certificate must be kept in the patients chart. Second, you need a prescription for the necessary footwear from the doctor who is <b>treating the foot condition<i>.</i></b> <table class="clsTableCaption" style="float: center;"> <tbody> <tr> <td><img src="https://opedge.com/Content/OldArticles/images/2005-03_07/Table2_SteppingOut.gif" alt="Table 2." /></td> </tr> <tr> <td>Table 2.</td> </tr> </tbody> </table> As a qualified individual, you may 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. For additional information, two examples of helpful websites are <a href="https://opedge.com/2679">www.safestep.net</a> and <a href="https://opedge.com/2680">www.surefitlab.com</a> Â . <i>Séamus Kennedy, BEng (Mech), CPed, is president and co-owner of Hersco Orthotic Labs, New York City, New York.</i>
