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DIABETIC SHOE DOCUMENTATION REQUIREMENTS FOR MEDICARE PATIENTS

Dear Physician:

Medicare covers therapeutic shoes and inserts, (custom made or custom molded) 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. In order for these items to be covered for your patient, the following criteria must be met:

An MD or DO (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. That 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 MD or DO.

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

A Detailed Written Order. This can be prepared by the supplier but must be signed and dated by you to indicate agreement. A copy of an office visit note from your medical records that shows you are managing the patient’s diabetes. This clinical note should be dated within 6 months prior to delivery of the shoes and inserts. Either (a) a copy of an office visit note from your 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, you must sign, date, and make a note on the document indicating your 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 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 of the feet (e.g., a diagnosis of venous or arterial insufficiency or symptoms, signs or tests documenting one of these diagnoses. A diagnosis of hypertension, coronary artery disease, or congestive heart failure or presences of edema are not by themselves sufficient.)

A certification form stating that the coverage criteria described above have been met. This form will be provided by the supplier but must be completed, signed, and dated, by you after the visit described in #2 and #3. If option 3(b) is used, that visit note must be signed prior to or at the same time as the completion of the certification form. However, this form is not sufficient by itself to show that the coverage criteria have been met, but must be supported by other documents in your medical records as noted in #2 and #3.