A Centers for Medicare & Medicaid Services (CMS) senior official has released a letter to physicians detailing the coverage and documentation requirements for diabetic shoes.
Robert D. Hoover Jr., MD, MPH, FACP, the senior medical director for the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C, released the following document, titled, “Therapeutic Shoes for Diabetics: Physician Documentation Requirements for DME Reimbursement,” in February. The document is quoted in its entirety:
Medicare covers therapeutic shoes and inserts for persons with diabetes. This statutory benefit is limited to one pair of shoes and up to 3 pairs of inserts or shoe modifications per calendar year. However, in order to qualify, the Medicare statute mandates specific coverage and documentation requirements that must be met.
The need for therapeutic shoes must be certified by a physician who is an M.D. or D.O. and who has the primary responsibility for treating the patient’s systemic diabetes. This physician must:
- Document in the patient’s medical record that the patient has diabetes; and
- Certify that the patient is being treated under a comprehensive plan of care for diabetes, and that the patient needs diabetic shoes; and
- Document in the patient’s medical record the presence of 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 and evidence of callus formation of either foot, or
- Foot deformity of either foot, or
- Poor circulation (i.e., small or large vessel arterial insufficiency) in either foot.
A new certification statement, signed and dated by the treating physician, must be provided on a yearly basis in order to obtain a new pair of shoes or inserts.
It is important to note that even though you may complete and sign a form attesting that all of the coverage requirements have been met, there also must be documentation in your records to indicate that you are managing the patient’s diabetes and that one of the conditions listed in 3a-3f is present. If requested by the supplier, you must provide copies of those records.
As with all items covered by Medicare, there must be a detailed written order for the items that are provided. The specifics of what is being provided may be entered by the supplier, but the physician must sign and date the order. Signature or date stamps are not acceptable. A new order is required yearly.
Although the requirements listed in 1-3 above must be documented by the MD or DO who has the primary responsibility for treating the patient’s diabetes, the order could be provided by that physician or by a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.
Physicians can review the complete Local Coverage Determination and Policy Article titled Therapeutic Shoes for Persons with Diabetes on the CIGNA Government Services (CGS) website at http://cignagovernmentservices.com/jc/coverage/LCDinfo.html. It may also be viewed in the national Medicare Coverage Database at www.cms.hhs.gov
Physicians are reminded that in order for these items to be reimbursed for your patients, the DME supplier will need to collect the medical documentation described above. Providing this documentation is in compliance with the HIPAA Privacy Rule. Also note that you may not charge the supplier or the beneficiary to provide this information. Please cooperate with the supplier so that they can provide the therapeutic shoes and inserts that are needed by your patient.
Robert D. Hoover, Jr., MD, MPH, FACP
Durable Medical Equipment Medicare Administrative Contractor, Jurisdiction C
To read the original document, visit www.cignagovernmentservices.com/jc/pubs/news/2009/0209/cope9304.pdf