Documenting Therapeutic Shoes

Remember that MasterCard commercial? “MasterCard. It's everywhere you want to be.” It's the same with documentation. Every product category you want to provide to assist in the growth of your business has associated documentation requirements. Maybe our new slogan should be “Documentation. It's everywhere you want to be.”

For example, many providers have added therapeutic shoes for diabetics in recent years, but there are strict Medicare documentation requirements associated with providing the product. In order for these items to be covered for your patient, the following criteria must be met:

An M.D. or D.O. (termed the “certifying physician”) must be managing the patient's diabetes under a comprehensive plan of care and must certify that the patient needs therapeutic shoes. The certifying physician must document that the patient has one or more of the following qualifying conditions:

• Foot deformity

• Current or previous foot ulceration

• Current or previous pre-ulcerative calluses

• Previous partial amputation of one or both feet or complete amputation of one foot

• Peripheral neuropathy with evidence of callus formation

• Poor circulation

According to Medicare national policy, it is not sufficient for a podiatrist, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) to provide that documentation (although they are permitted to sign the order for the shoes and inserts). The certifying physician must be an M.D. or D.O.

The following physician documentation is required in order for Medicare to pay for therapeutic shoes and inserts and must be provided by the physician to the supplier, if requested:

1. A detailed written order.

2. A copy of an office visit note from the patient's medical records that shows the physician is managing the patient's diabetes. This note should be within six months prior to delivery of the shoes and inserts.

3. Either (a) a copy of an office visit note from the physician's medical records that describes one of the qualifying conditions or (b) an office visit note from another physician (e.g., podiatrist) or from a PA, NP or CNS that describes one of the qualifying conditions. If option (b) is used, the certifying physician must sign, date and make a note on that document indicating their agreement and send that to the supplier.

   The note documenting the qualifying condition(s) must be more detailed than the general descriptions that are listed above. It must describe (examples not all-inclusive):

   • The specific foot deformity (e.g., bunion, hammer toe, etc.); or

   • The location of a foot ulcer or callus or a history of one these conditions; or

   • The type of foot amputation; or

   • Symptoms, signs, or tests supporting a diagnosis of peripheral neuropathy plus the presence of a callus; or

   • The specifics about poor circulation in the feet, e.g., a diagnosis of venous or arterial insufficiency or symptoms, signs, or test documenting one of these diagnoses. A diagnosis of hypertension, coronary artery disease, or congestive heart failure or the presence of edema are not by themselves sufficient.

4. A certification form stating that the coverage criteria described have been met. However, this form is not sufficient by itself and must be supported by other documents in the certifying physician's medical records as noted in items 2 and 3.

New documentation from the patient medical record is required annually in order for Medicare to pay for replacement shoes and inserts.

In addition, before selecting the specific items that will be provided, you must conduct and document an in-person evaluation of the patient. Refer to the local coverage determination (LCD) for specific documentation requirements of the supplier in-person evaluation.

Make sure you review the LCD and policy article associated with diabetic shoes, in addition to the excerpts from the article, for the most current information. (A new LCD was scheduled to take effect Feb. 4.)

Of 18,433 claims for HCPCS A5500 (diabetic shoe insert) analyzed for its customers during the fourth quarter of 2010, the majority of denials were from CO-B7 and CO-18 reason codes, with denial rates of 20 percent and 17 percent, respectively. Source: RemitDATA, 866/885-2974 or www.remitdata.com.

Read more Working Down Denials columns.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.