If you as a podiatric physician have not established yourself as the expert of the diabetic foot within your area, now is the time. There is no reason why you shouldn’t be the “go to” guy or gal in your community when it comes to treating, managing and preventing diabetes-related lower extremity complications. Managing the diabetic foot is all about a team approach and establishing yourself as the quarterback will not only improve the quality of care for your patients but it can also greatly enhance your business. The podiatric literature is replete with dozens of studies demonstrating the correlation of foot pressures and ulceration. As the community foot and ankle specialist who reads and is aware of issues relating to pressure and ulceration prevention, you should ensure that diabetic shoes are an integral part of your “diabetic foot program.” Six Key Points For Providing Diabetic Footwear If shoes and inserts are not a part of how you manage your diabetic patients, consider the following points. 1. Pressure relief correlates to a reduced incidence of ulceration. Studies show ulceration precedes most amputations. Appropriate fitting inserts and supportive shoes can significantly reduce the risk of ulceration. 2. Poor, ill fitting shoes correlate to skin irritation and ulceration. If you aren’t looking at your patient’s shoes, you are missing a critical area of examination. 3. Who would you like dispensing shoes to your diabetic patients? A pharmacy? A local DME company or Charlie’s traveling diabetic shoe company? Don’t be a spectator when it comes to your patient’s shoes. 4. Providing a comfortable shoe that pads and protects your patient’s foot will make him or her a patient for life. 5. Make one patient happy with a pair of comfortable protective diabetic shoes and many more will come. 6. Medicare reimburses approximately $300 for one (off the shelf) pair of extra-depth therapeutic shoes and three sets of heat molded/custom multilaminar insoles. Your cost for shoes and inserts can range between $120 to $200. If you don’t provide shoes for your patients, someone much less qualified will. As the cost of diabetes-related lower extremity complications has skyrocketed over the past decade, Medicare developed the diabetic shoe program with the idea of saving money by preventing ulcers. Although debate still looms over whether diabetic shoes can reduce the overall amputation rate, the bottom line remains that pressure and friction in a neuropathic diabetic patient lead to devastating consequences and there is no one better to address those issues than the podiatric physician. An Overview Of The Medicare Shoe Bill Diabetic patients with one or more of the following diagnoses may receive one pair of therapeutic shoes (A5500 x 2) and three pair of heat-moldable multilaminar inserts (A5509/ A5511 x 6) per year. A patient who received shoes August 6, 2003 will be eligible for another pair August 6, 2004. Patients who are eligible for this shoe bill must have diabetes mellitus with an accompanying history of partial or complete amputation of the foot; a history of previous foot ulceration; a history of pre-ulcerative callus formation; foot deformity or poor circulation. For these patients, you should use the appropriate ICD-9 diagnosis codes 250.0 – 250.91. As we all know, documentation is essential. Your documentation must include: • a signed certificate of medical necessity (CMN); • the shoe prescription (including size, style and required modifications); • a statement that the heat moldable inserts achieve total contact; • invoices from the shoe/insert order; • a statement of fitting/pick-up; and • notations of any adjustments you make at fitting. How Can You Get Started? 1) First of all, you must have a DMERC supplier number. Information on how to obtain one of these is available through your Medicare carrier. We also strongly recommend obtaining a state DME supplier number although a Medicare DME number is typically required in order to apply (see http://www.palmettogba.com). Remember that most coverage is retroactive, so you may begin supplying shoes within weeks after you apply for a number. SureFit is another great resource when it comes to getting started with DME numbers and other aspects of the diabetic shoe program. The Web site for SureFit is http://www.surefitlab.com/index.html. 2) Develop a certificate of medical necessity that is thorough, easy to read and easy to sign. Before you can bill Medicare or Medicaid for shoes, you must provide this CMN. Be sure to check state regulations. Medicare will accept Medicaid-approved CMNs, but Medicaid will not always accept Medicare’s recommended CMN. 3) Select the shoes you wish to carry (see “What Kind Of Shoes Should You Offer?” below) and then contact those companies for a display packet. There may be a cost involved, but having sample shoes and educational literature in your office is well worth the investment. 4) Get the word out. Let your diabetic patients know you are now a certified supplier of diabetic shoes. Educate the primary care doctors in your area regarding the benefits of therapeutic shoes. Purchase a mailing list from the American Diabetes Association of diabetics in your area. Use your traditional media outlets such as newspaper ads and radio. However, don’t go overboard as you want to avoid being perceived as more of a salesperson than a doctor. Get your staff involved. Remember, a “shoe-informed” back office assistant will make a huge difference in the success of this program. Make Your CMN Stand Out The CMN form is critical for your success in the diabetic shoe program. Despite that fact that your patient’s primary doctor may not have looked at your patient’s feet in 20 years, he or she can still refuse to sign the form. If the primary doctor is well educated and well informed about risk factors among diabetic patients, he or she will gladly sign it. Here are some things you must convey to your referring primary doctors about diabetic shoes. • Let them know you are doing an actual diabetic exam on these patients to determine if they qualify for shoes. Pharmacies, DME companies, etc., do not do diabetic foot examinations. • Write down or call and tell the doctor the results of your exam. • Make the primary doctor aware of the components of the diabetic shoe. Emphasize for example that the shoe is an extra-depth shoe with a multilaminar insole. Also make sure the PCP is aware that you are not dispensing a $20 shoe. • Let the signing doctor know that the patient is involved in your unique comprehensive diabetic foot program that includes diabetic shoes. Make him or her aware that you will be following up with the patients to see if the shoes you dispensed are accomplishing the desired effect. • Develop a risk classification for your patients that will allow the signing physician to know what diabetic risk category the patient is in. The University of Texas diabetic foot risk classification is perfect for this. (See http://www.diabeticfoot.org/Research.html#Anchor-The-11481.) • Make your CMN unique to your practice. Put some handwritten notes on your CMN or insert some information on how proper shoes can lower the risk of amputation. Whatever you do, make sure your CMN looks professional and ensure that it does not look a pharmacy or DME company CMN. Pointers For Measuring And Ensuring A Proper Fit Currently, more diabetic shoes are being dispensed from “medical supply (DME)” stores than out of podiatric offices. Why? Prescribing DPMs certainly know more about the foot and diabetic risk factors than any pedorthist or physical therapist. Much of what is involved in fitting and molding patients for shoes is common sense. Here are some considerations. • Measure right the first time. The first thing you need to have is an accurate measuring device. Some diabetic shoe companies have their own specific measuring tools for their shoes so it’s important to measure correctly for the prescribed shoe. When measuring the patient, be sure to measure both feet as sizes may differ. Measure the width of the foot and be aware and educated as to what shoe types come in the wider widths. Avoid putting a patient with a 4E width into an “extra wide shoe.” Some shoes only go up to an extra wide width while others (like the New Balance 810) go up to a 4E width. Include the size and width on your prescription along with your recommended shoe. Most vendors will send you information or will even send a rep to your office to educate you on how to appropriately and accurately measure for shoes. Don’t be afraid to ask. • When the patient comes in for fitting, it is well worth your time to make sure the shoe fits his or her foot well. If it doesn’t fit, reorder. Make sure you also have a policy in place that informs your patients when you will and will not accept returned shoes for replacement. • Be aware of the rules on molding inserts. Medicare will only cover diabetic inserts that are either custom fabricated (A5511) or heat molded by an external heat source (A5509). For heat molded, pre-fabricated inserts, Medicare mandates that these inserts must achieve “total contact” with the patient’s foot. Keep in mind that many prefabricated inserts sold as heat moldable diabetic devices do not meet this criteria. • Lastly, keep in mind that some patients with certain foot types (cavus foot) will absolutely require a custom made device as opposed to a prefab, heat molded insert. In addition, patients with severe deformity (Charcot osteoarthropathy or a partial amputation) should not use a heat moldable prefab. In these cases, you should take a cast impression and send for a custom insert (A5511). Companies like SureFit fabricate custom devices and can help with other additions like toe fillers and bars. Other Pearls For Maintaining A Thriving, Efficient Program • Don’t get caught up with high profits while compromising quality and proper fit. Avoid using cheap shoes and cheap inserts in order to increase profits. Word gets around quick and sometimes the shoes you dispense represent you as a physician. Provide a great product and people will come. • Consider sending the CMN with the patient to get it signed. Sometimes mailing the CMN takes weeks to months to get it returned. Also be aware that Medicare requires an original copy of the CMN in the chart. • Always include a self-addressed stamped envelope when you are mailing the CMNs or even if you are sending the CMN with the patient. • Send reminders to patients when it is time for them to change their inserts or when they are eligible for new shoes. You’ll be surprised at how many patients come in that you haven’t seen in a year. • Start the process a month before the patient is eligible for new shoes. It will take four to six weeks from evaluation of the patient’s feet to fitting of the shoes. • Many private insurers also cover diabetic shoes and inserts (A5500 x 2, A5509 x 6). It behooves you to have someone call on these patients to see if their insurance will cover yearly therapeutic shoes. • Take great care in measuring your patients’ feet and set policies on when you will and when you won’t replace or accept returned shoes. Reordering and returning shoes can eat up your profit if it gets out of hand. Jonathan Moore, DPM, MS, is a former University of Texas Diabetic Foot Fellow who practices in Somerset, Ky. Kimberly Moore, OTR, currently serves as the diabetic shoe coordinator at Cumberland Foot and Ankle Center in Somerset, Ky.