If the Shoe Does Not Fit, Do Not Deliver

Diabetic shoes and inserts definitely do not “fit” the Cinderella story. Providers have always been responsible in supplying the shoes and inserts that are medically necessary for diabetic patients, but Medicare policy has recently been modified to verify documentation and fitting criteria for the program’s beneficiaries.

Diabetic shoes have strict criteria and guidelines that must be met for reimbursement. First, the patient must have a diagnosis of diabetes mellitus. The ICD-9 codes for coverage range between 250.00 and 250.93, and must be transmitted as a five-digit code or the claim will receive a CO-16 denial. In other words, the claim needs additional information for processing. If this is the case, you may verify the five-digit code with the “certifying” physician and retransmit the correct diagnosis code.

Second, the patient must have one or more of the following conditions documented: (a) poor circulation in either foot; (b) foot deformity of either foot; (c) peripheral neuropathy with evidence of callus formation of either foot; (d) history of pre-ulcerative calluses of either foot; (e) history of previous foot ulceration of either foot; (f) previous amputation of the other foot or part of either foot.

Additionally, the certifying physician managing the patient’s systemic diabetes must be treating the patient under a comprehensive plan of diabetes care, and confirm that the patient medically meets all the stated criteria for diabetic shoes.

A physician’s order, supplied in the format offered by the DMERC, must be completed, and must be signed and dated by the certifying physician. But, the order must be prescribed by a podiatrist or other qualified physician knowledgeable in the fitting of diabetic shoes and inserts. This is a clarification in the revised policy effective April 1, 2004. The shoes and inserts “must be fitted by a podiatrist, or other qualified individual such as a pedorthist, orthotist or prosthetist.” The only exception to this rule is if a certifying physician practices in a “defined” rural or health-professional shortage area. Per Medicare guidelines, the prescribing physician can be the supplier of the footwear.

When billing all diabetic shoes and inserts, a “KX” modifier must be added to verify the provider has met all documentation requirements set forth by policy. The LT (left) and RT (right) modifier must only be used if billing for one unit of service. When billing diabetic shoes, you will bill a quantity of “2” for a pair.

On April 1 of this year, two HCPCS codes changed for diabetic inserts. The new codes must be transmitted for dates of service on or after July 1, 2004. HCPCS code A5509 has changed to HCPCS code K0628. HCPCS code A5511 has changed to K0629.

The Pedorthic Footwear Association (PFA) has requested that the descriptors for SADMERC’s two new K codes be modified so that the inserts can be accommodated to existing medical policy descriptions for the A5500 and the A5501 diabetic shoes. PFA feels there are discrepancies between the old and new HCPCS codes for the inserts that could lead to patient complications, such as possible amputation and foot ulcers. Each patient has a unique situation, and pedorthists need the flexibility to determine what is best for their patients.

Of the 16 million Americans with diabetes, 25 percent are estimated to develop foot problems related to the disease. Alarming statistics from the Centers for Disease Control and Prevention, from 2000-2001, estimate that 82,000 lower limb amputations due to diabetes occur every year. Most experts agree that most are preventable with comprehensive foot care programs, including footwear that is properly fit.

Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS, Inc. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at [email protected].