Secrets To Billing For Diabetic Shoes

Marty Chalfin, CPed

Given the escalating prevalence of people with diabetes, chances are you will be seeing more and more patients in need of diabetic footwear. With this in mind, this author reviews recent changes in the Therapeutic Shoe Program for Diabetes and discusses how to navigate the paperwork trail to help ensure timely dispensing of shoes and appropriate reimbursement.

The Therapeutic Shoe Program for Diabetes (TSPD) was created to help prevent lower limb amputations and may very well be the only true preventative program Medicare offers. In order to offer this great benefit to your patients with diabetes — and be profitable in doing so — it is important to have a simple and efficient process in place to ensure you are compliant and prepared to avoid the headaches of a Medicare audit gone bad.

   Accordingly, let us take a closer look at a simple seven-document solution, tailored specifically to the DPM, which will help make you audit proof and allow you to avoid these potential headaches.

   Medicare has recently issued statements modifying the paperwork necessary to provide patients diabetic shoes and inserts under the TSPD. When it comes to the TSPD, what can make policy issues confusing is the somewhat unique nature of those who are allowed to supply diabetic footwear. A supplier can be a durable medical equipment company, a pharmacy, an orthotics and prosthetics (O&P) company, or a DPM practice. When Medicare issues policy statements regarding the TSPD, they try to explain how the process should go in one way that covers all of these different channels. The results can be pretty confusing.

   Of the various types of suppliers allowed to dispense diabetic footwear under the TSPD, the DPM practice is typically the only one having someone on staff qualified to make a diagnosis. This gives DPMs a distinct advantage. This advantage gives you the flexibility to meet Medicare’s requirements in several different ways. Rather than going through all the different options, let us take a look at one simple method to ensure you are always in compliance with the TSPD.

   Here are the seven simple pieces of paper you need.

1) Statement of certification
2) Note of diagnosis
3) Prescription
4) Notes during measuring
5) Packing slip
6) Notes during dispensing
7) Authorization for payment and warranty

   You would fill out the first three prior to ordering shoes. You and your staff would gather the remaining four documents during the process of fitting and dispensing the shoes to the patient. The KX code in the billing process signifies that you have the information contained in these documents on file. Keep these seven pieces of paper in the patient’s chart so you can easily retrieve them as a group if Medicare or the insurance carrier asks for them.

   The following is a description of each of these documents, their purpose and some hints in obtaining these documents painlessly.

   1) Statement of certification. This is a single-page standard document in which the MD or DO states: that the patient has diabetes (ICD Code); that the patient has one or more of six qualifying conditions; and that the patient would benefit from diabetic shoes and inserts under the TSPD.

   The qualifying conditions are simply listed as:

• history of partial or complete amputation of the foot;
• history of previous foot ulceration;
• history of pre-ulcerative callus;
• peripheral neuropathy with evidence of callus formation;
• foot deformity; and/or
• poor circulation.

   Remember that the TSPD is a proactive program that will save limbs by giving patients shoes before they have serious issues. By signing the statement of certification, the MD/DO is actually ordering the supplier to dispense the footwear to the patient.

How To Facilitate A Quick Turnaround From The MD/DO

2) Note of diagnosis. This requirement of the TSPD is the one that usually causes the most confusion. However, having an effective process in place makes it very simple. The note of diagnosis is a simple page of text — from a qualified individual — diagnosing the condition that qualifies the patient for shoes. Obtaining this note is where the DPM’s distinct advantage comes into play. As a qualified individual, you can simply make the diagnosis, write the note and have it initialed by the MD/DO.

   Other suppliers have do one of the following: obtain the notes of the MD/DO diagnosing the condition (which he or she often will not have); send the patient back to the MD/DO to make the diagnosis and then obtain a copy of the notes; send the patient to another qualified individual to make the diagnosis (and risk losing the patient to a DPM who also supplies shoes); or find some other way to get the diagnosis made and into the MD/DO’s medical record.

   While having the MD/DO initial your notes may seem like an extra unnecessary step, Medicare’s stand on this is pretty simple. If the MD/DO is going to certify that, in addition to having diabetes, the patient has one of the six qualifying conditions, common practice suggests the MD/DO should have that diagnosis somewhere in the notes before signing the statement. Medicare simply wants to verify that is the case and that medical necessity for the item has been established.

   When asking MD/DOs to initial your diagnosis, you want to make it as easy as possible for them. The best way to do this is to have a short separate page with the transcription of the subjective, objective, assessment and plan (SOAP) note, or other simple text describing the patient’s qualifying condition. The MD/DO will certainly initial and keep a page of text that simply describes the condition on the statement of certification that he or she is signing. In fact, the MD/DO may feel more comfortable signing the statement of certification if a note of diagnosis is included.

   Consider the following example. If the statement of certification states that the patient has “poor circulation,” the note of diagnosis might read as follows:

   Patient Mary Smith entered on 12/1/2010 for diabetic-related foot complications. Patient is found to have Class B absent DP pulse and Class B absent PT pulses. Patient is found to have peripheral vascular disease. Counseled patient regarding therapeutic footwear. Faxing letter of medical necessity and diagnosis to primary care physician.

   The best way to make this as simple as possible for MD/DOs is to have your initial fax to them include the following:

• a cover letter explaining your request;
• the statement of certification; and
• your note of diagnosis.

   The cover letter from the DPM to the MD/DO might explain the value of shoes and inserts for the at-risk patient with diabetes; the requirement that the MD/DO is treating the patient for diabetes; and an explanation that the patient has one of the qualifying conditions on the attached forms. Then you can instruct the MD/DO to sign the statement of certification, initial the note of diagnosis and/or put it in the patient’s chart, and fax both items back to you. Sample cover letters are available on the Medicare website ( or from most shoe manufacturers.

   Having a working relationship with the primary care physician can go a long way. You may want to visit some local MD/DOs — particularly if many of your patients with diabetes are referred by them — to talk about the benefits of diabetic footwear.

   A short visit to a local MD/DO may result in faster paperwork turnaround as well as more referrals. If establishing a working relationship with an MD/DO is unsuccessful, another effective method is to get the patient involved. If a particular MD/DO declines to sign and initial the paperwork, you can describe the paperwork necessary to the patient. Then ask the patient to visit his or her doctor for the signatures.

   Medicare Article L11535 Revision 9/1/2009 states that the certifying physician must either “personally document” or “obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of a podiatrist …” on one or more of qualifying conditions checked on the statement of certification. Medicare Article L11535 also states that “The certification statement is not sufficient to meet the requirement for documentation in the medical record.”

   The key is to keep it simple and straightforward for the MD/DO to sign and initial the paperwork.

When Shortcuts Can Actually Delay A Signature From The MD/DO

Some DPMs may copy an entire page of the patient’s chart in which the qualifying condition was diagnosed. That same page may contain much more extraneous information that the MD/DO may not want to initial. It is far easier to transcribe that original SOAP note with the diagnosis or make a separate note of the qualifying condition for the MD/DO to initial.

   Some podiatrists are using the Comprehensive Diabetic Foot Exam (CDFE) in place of the note of diagnosis. There are many different versions of the CDFE that are available online at no charge, available through some shoe vendors or available through other third parties at little or no cost. In many cases, the CDFE is just another more extensive “check off” sheet.

   If you are using the CDFE as the note of diagnosis, it is best if the form includes some text describing the condition. Keep in mind that MD/DOs may be more hesitant to initial a two-page examination form rather than a single sheet with a single diagnosis. While the CDFE can certainly be a valuable tool for the DPM, it may not always be the best tool for obtaining the documentation you need for obtaining the MD/DO’s initials on the note of diagnosis.

Other Keys To Documentation

3) Prescription. The DPM can write this directly in the patient’s chart as an in-line note or put it into the patient’s chart as a separate piece of paper. A separate piece of paper is typically best as it is easier to find and copy in the case of an audit request. Whichever method you use, in addition to patient specific instructions, be sure to also include the quantity prescribed and the types of inserts (e.g., one pair of extra-depth diabetic shoes and three pairs of heat moldable inserts).

   Once you have the three pieces of paper above, you can feel confident to order the shoes from your vendor. The rest of the paperwork is generated by your office with some signatures from the patient.

   4) Notes during measuring. One should take these notes during the visit with the patient. Your notes serve as proof that the patient was in your office being measured for footwear. The requirement for these notes was implemented by Medicare recently to deter suppliers who may be just calling the patient on the phone and asking for his or her shoe size.

   5) Packing slip. The packing slip is typically in the box that you receive from the vendor with the shoes and inserts. If you are buying shoes from one of the major shoe companies that advertise A5500 shoes and A5512 or A5513 inserts, the Pricing, Data Analysis and Coding (PDAC) Medicare letters are usually posted on the vendor’s website.

   The packing slip should detail the products purchased and serves as proof that you gave the patient Medicare qualified shoes and inserts (and not flip-flops). By chance, if you are a DPM who manufactures your own A5513 custom inserts, you should list the materials that you used in making these inserts and post this in the patient’s chart.

   6) Notes during dispensing. You should take these notes during the visit with the patient. They serve as proof that the patient was in your office to try on the shoes. Medicare recently implemented this to deter suppliers who may just be mailing the shoes to the patient.

   7) Authorization for payment and warranty. The patient and a witness (a member of your office staff) sign the authorization when you and the patient are satisfied with the fit and function of the shoes and the inserts. It is a signed statement by the patient that he or she has received the shoes and inserts; is satisfied with the fit; and may be liable for any payment Medicare does not pay. This may include the co-payment of 20 percent if the patient does not have secondary insurance; deductibles if they have not been met yet; or the full Medicare reimbursement amount if the patient had received shoes and inserts within the same calendar year.

   This document should also advise the patient that he or she has a 30-day warranty in which he or she can exchange or return the product. It may also have a statement that the patient was given the supplier standards and shoe break-in instructions.

   The date of service for billing Medicare is when the patient signs the authorization of payment and warranty, and takes the shoes home from your office. The requirement is that the date of service is later than the statement of certification and notes of diagnosis. Also, the date of service cannot be later than six months after the patient’s last visit with the MD/DO.

Final Notes

In the past several years, Medicare has made it much more difficult for non-DPMs to dispense diabetic footwear under the TSPD. The American Podiatric Medical Association has worked hard to ensure that DPMs were exempt from many of the DME requirements, such as accreditation and surety bonds. As a result, DPMs are at a great advantage in the competition to dispense diabetic shoes to patients in a particular area.

   These recent rule changes — particularly those involving the note of diagnosis, notes of measuring, and notes of dispensing — are again to the advantage of the DPM. Podiatrists should take advantage of this position and do their best to fit more patients with shoes to help prevent diabetic amputations.

   The statement of certification, note of diagnosis and prescription with appropriate signatures are easy for a DPM to obtain. You are part of the healthcare team and are able to diagnose and communicate those findings to the MD/DO responsible for the patient’s overall diabetes management. These same documents are much more difficult for a non-DPM supplier, such as a CPed, to obtain since a CPed cannot diagnose the qualifying foot conditions. The CPed also has the more difficult task of having the MD/DO write and document the diagnosis and provide his or her notes. In many cases, the MD/DO may not have even examined the patient’s feet and simply state in the chart, “Refer to DPM.”

   If you have a simple and efficient process in place, such as the seven pieces of paper described above, responding to an audit will take only a few minutes. It will not only help you provide a great benefit to your patients to help them avoid amputation, it will also help your practice remain profitable.

   Mr. Chalfin has been working with the Diabetic Shoe Program since 2003. He joined Dr. Comfort in 2007 as an Account Manager. One can reach Mr. Chalfin at or (877) 379-3674.

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