“I read the Medicare DME requirements for diabetic shoes and inserts. I am still confused and am seeking clarity. I know for diabetic shoes, it requires a MD/DO to certify that patient has diabetes with neuropathy and thus, qualifies for diabetic shoes and 3 custom insoles. It is my understanding that Medicare only covers orthotics if the patient is diabetic and as stated above, is certified to have diabetes with neuropathy. I have seen other physicians use the KX modifier to get orthotics incorrectly paid. My question is: If I just want to dispense the custom molded diabetic insoles (three pairs of orthotics/diabetic insoles as allowed by Medicare — and not the shoes), are there separate rules or are they the same rules? Is it legal to do a cash pay for diabetic/soft custom insoles? Any other tips you have found useful in your practice? Have you in your practice just dispensed the insoles and not the shoes?”
In order to determine whether or not a diabetic patient can be dispensed and fit with 3 pair of either heat molded or “custom made” inserts without being accompanied by one pair of extra depth, therapeutic shoes, it is important to access the Medicare Benefits Policy Manual, Chapter 15 – Covered Medical and Other health Services, specifically Section 140 – Therapeutic Shoes for Individuals with Diabetes.
It states within Section 140: under Subsection B, Coverage:
“4. Separate Inserts
Inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the patient has appropriate footwear into which the insert can be placed. This footwear must meet the definitions found above for depth shoes and custom-molded shoes.”
Two Additional points:
1. If the patient comes back within the same calendar year and then wants a pair of extra depth, therapeutic shoes (ie. diabetic shoes), the answer is quite simple. No.
This is a “one bite of the apple” experience. The patient would have to wait until the next calendar year.
2. If a patient wants an additional pair or pairs of heat molded or custom inserts above and beyond the normal 3 pair, the answer once again is quite simple. Yes. However, an ABN should be appropriately filled out and the patient will have to pay out of pocket.
If the patient is dispensed and fit with either 3 pair of heat molded or custom inserts, but not a pair of extra depth, therapeutic shoes, the same qualifying rules apply as if the patient received the inserts and the shoes:
The need for diabetic shoes must be certified by a physician who is a doctor of medicine or a doctor of osteopathy and who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care. This managing physician must:
• Document in the patient’s medical record that the patient has diabetes;
• 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 record that the patient has one or more of the following conditions, which can also come from the medical records of the treating/dispensing DPM:
o Peripheral neuropathy with evidence of callus formation;
o History of pre-ulcerative calluses;
o History of previous ulceration;
o Foot deformity;
o Previous amputation of the foot or part of the foot; or
o Poor circulation.
Following certification by the physician managing the patient’s systemic diabetic condition, a podiatrist or other qualified physician who is knowledgeable in the fitting of diabetic shoes and inserts may prescribe the particular type of footwear necessary.
E. Furnishing Footwear
The footwear must be fitted and furnished by a podiatrist or other qualified individual such as a pedorthist, an orthotist, or a prosthetist. The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area. It is left to the discretion of each carrier to determine the meaning of “in the area.”
PS: If orthotics are reimbursed due to the fact that the KX modifier (DOCUMENTATION ON FILE Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service. This modifier is used on all line items for claims that are submitted to the DMERC.) was incorrectly appended to the HCPCS Level II orthotic codes, L3020 or L3000, there is only way to describe this reimbursement: Inappropriate aka Fraudulent.
This is my opinion.
Michael G. Warshaw
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