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Understanding The Diabetic Therapeutic Shoe Program

   One of the first patients I saw when I started practice many years ago was a diabetic patient who presented with medial ulcerations on both great toes. I aggressively treated the ulcerations and offloaded the toes. After the lesions had healed, I triumphantly told the patient she could go back to wearing her regular shoes.    Two weeks later, she returned to the office with the ulcers back in full bloom. As I should have done earlier, I had a discussion with the patient about shoes and found out she was wearing the same shoes she had worn for many years and could not afford any other shoes. I have seen the same scenario repeated multiple times in my practice over the ensuing years.    In 1998, Congress passed the Diabetic Therapeutic Shoe Bill, which made it possible to provide depth shoes and custom inserts, funded by Medicare, to patients with diabetes. This has been a tremendous help in the management of the diabetic foot. The question is: who should be the expert in this program? Should it be the shoe salesman on the corner, the pharmacist who has taken a weekend course, the physical therapist or the entrepreneur who takes a bus to nursing homes and assisted living centers to provide “diabetic shoes to all”?

Why DPMs Are Uniquely Positioned To Lead The Program

   I believe the podiatrist should be the expert and manager in the diabetic shoe arena as well as the other medical portions of diabetic foot care. Podiatrists provide a unique medical service to patients with diabetes when we manage their foot problems. We should be the very best at preventing diabetes-related problems in the lower extremity. When we do our job correctly, we can provide limb- and sometimes life-saving service to our patients with diabetes.    It is generally recognized in the medical community that podiatrists are unsurpassed at providing lower extremity care for the diabetic population. Shoes play a very important role in the management of these patients. Even the very best wound care physician, surgeon or at-risk foot care manager in the world will not be effective if the patient is wearing a substandard shoe.    As I have lectured across the country in the last several years on this and other subjects, I have found that many podiatrists do not participate in the Diabetic Therapeutic Shoe Program. When I ask them why they do not, some of the answers include:    • It is too much of a hassle in the office.    • I do not want to have an inventory of shoes.    • I do not have a durable medical equipment (DME) provider number.    • I do not know how to start.    • I have heard the billing is a problem for the office.    • I am not a shoe salesman.    If we as podiatrists do not run the diabetic shoe program in our offices, then others will fill the vacuum. As with other programs, some have abused the shoe program. The best way to ensure this does not happen is to make our referring physicians and patients aware that we are the experts who control the program and provide the service.

Who Qualifies For The Shoe Program?

   Diabetic shoes, inserts and/or modification to the shoes are covered if the patient meets the following criteria: 1) the patient has diabetes mellitus (ICD-9 diagnosis codes 250.00-250.91); and 2) the patient has one or more of the following conditions:    a. Previous amputation of the other foot, or part of either foot    b. History of previous foot ulceration or either foot    c. History of pre-ulcerative calluses of either foot    d. Peripheral neuropathy with evidence of callus formation on either foot    e. Deformity of either foot    f. Poor circulation in either foot; and 3) the certifying physician is managing the patient’s systemic disease under a comprehensive plan of care for his or her diabetes, and the patient needs diabetic shoes.    According to the criteria, most of the diabetic patients in our practices would qualify for the shoe program. Notice that only one of the above criteria (the second) needs to be present in order for the patient to qualify for the shoes.

Combating Common Misperceptions And Fears

   I have participated in the program from the beginning and have been very happy with the results and the great help these shoes provide to my patients and their medical well-being. After all is said and done, we are providing a needed medical service to our patients. Our overall goal is always to keep our patients with diabetes ambulatory and prevent potentially grave foot problems. The shoe program helps us do this.    Granted, there may be some apprehension and fear for some podiatrists who are wary about participating in the Diabetic Therapeutic Shoe Program. Let us address some of these previously stated concerns.    “It is too much of a hassle in the office” and “I do not want to have an inventory of shoes.” The key to having the program work in an office is to develop a system of ordering and dispensing that fits into the flow of the office and does not require significant physician time. This program is now an integral part of our diabetic care program and is not a hassle at all. No inventory of shoes is necessary in the office. All one needs is a catalogue of the available shoes. People are often very comfortable with ordering all sorts of things from catalogues so this is not a problem.    “I do not have a DME provider number.” One can easily obtain a DME supplier number. There are many other positive reasons to have this number besides shoes and every office should have a supplier number. The initial application is a typically long government form but one can fill it out on the Internet. There are many other items of durable medical equipment that can be billed to DMERC when one has a number. This helps to provide needed services to patients as well as adding income to your practice.    “I do not know how to start.” It is very simple to start participating in the program. I would recommend that the physician or someone else in the office become familiar with the companies that provide the shoes and talk with other providers about the companies they use. Talk to them about training, service, the return policy and how the overall experience has been for their practice. After getting a feel for what other offices have experienced, talk to the companies. Suppliers attend most of the larger podiatric meetings. One can get a good feel for them by talking with them, seeing the shoes and finding out about their methods of ordering, measuring and dispensing both the shoes and the inserts.     (Our office uses custom-molded inserts for most of our patients because they work the best and are what our patients need. The custom insert requires a cast and must meet the criteria of full foot molding as well as the material firmness to be reimbursed under the program.)    All of the companies have information on the Internet that can be very helpful. They are also willing to answer questions on the phone. When your practice is ready to begin, the company will either send the information for training the staff or representatives may be able to visit the office to help. All one has to do is mention the diabetic shoe program to patients and they will enthusiastically participate. It will become an important part of diabetic foot care for one’s practice.

How To Ensure Correct Coding For Shoes

   “I have heard that the billing is a problem for the office.” The billing for the DME has not been a problem for us but I know this has been a concern for some. Most of the shoe suppliers will do the billing for a fee but once the coding and modifiers are correct, the billing is simple. Once the billing is in place, it is part of the regular electronic billing one does for other insurance companies. The most common billing confusion I have found in looking at claims is that the place of service for DME should be the patient’s home, not the office. The place of service should be where the patient is using equipment, not where the equipment was dispensed.    The coding that one should use in the billing for the shoes is as follows:    • A5500: Extra Depth Diabetic Shoes    • K0628: Prefabricated Insert    • K0629: Custom Fabricated Insert    When doing the billing, it is important to use the correct modifier. Use the KX modifier in the modifier box to certify that one has the documentation from the primary care physician that the patient is under active care for diabetes. Also use the RT and LT modifier. Obtain the signed document as part of the system mentioned above. We have the document in our electronic medical record system, which automatically prints the document.    We enter the treating physician’s name on the form and fill out the form with the correct ICD-9 code so all the physician has to do is sign the form. We include a short (six-line) letter to the treating physician explaining the program. We have had very good success making the patient or family responsible for getting the form signed. The treating physicians appreciate the ease of just reviewing and signing the form. In many instances, once the treating physician is aware of the service being provided, he or she will then refer more patients to the office because the physician recognizes the great need for the depth shoes for his or her patients.    After signing the form and returning it, the patient comes to the office and the staff does the measuring and ordering of the shoe. The physician in our office has no time involvement in this process. After we send the shoes to the office, the patient makes an appointment for the shoe delivery. The staff fits the shoe and then informs me that the patient has the shoe. I have found I can go into the room and check the shoe quickly, which pleases the patients very much.    From start to finish, the physician time in the whole process is about five minutes. This process does require staff training and the willingness of the physician to be enthusiastic about the program. The staff can be most helpful in encouraging the patient about ordering, fitting and caring for the shoes. It is also required that patients sign a form that states they have received the shoes and instructions for their use. This is a requirement and needs to be in the chart. This form is also in our electronic medical record system and the staff gets this signature when the patient receives the shoe.    The place of service, where the shoes are used, is the patient’s home. If one enters the incorrect place of service, the claim will be rejected. In the units box on the form, enter two units per pair of shoes. One can dispense all the inserts at the same time so list six units (for three pairs of inserts) in the units box. If the practice does the billing with the correct code, modifiers and place of service, there should be no problem with payment.

Addressing Supplier Concerns

   “I am not a shoe salesman.” Many of the problems I have heard about are supplier-related issues. There are many suppliers to choose from and it is good to look around, talk with others who are using the program and get information from multiple companies.    If you are having problems with timely delivery, fitting, returns and the quality of the shoes, the supplier is the problem. The good companies will provide training, equipment and support as the practice sets up the program in the offices, and will help with problems that arise.

Final Notes

   Patients will not see the DPM as a shoe salesman but will appreciate him or her for providing a needed medical service as part of a comprehensive diabetic foot care approach in the office.    There are also economic advantages to participating in the shoe program. The reimbursement for the shoes and the inserts can help a great deal as added income in podiatric offices. This program adds to the income stream without adding a lot of physician time. Given the current reimbursement levels, the profit from participating in the Diabetic Therapeutic Shoe Program can not only help to maintain the shoe program, it can help reduce overall office overhead as well.    As part of a diabetic care program, the use of therapeutic shoes will help the patient medically while providing additional income for your office(s). I would encourage clinicians who treat patients with diabetes to make this program an integral part of their services. Dr. Stoker is a Fellow of the American College of Foot and Ankle Surgeons. He has a private practice in Salt Lake City, Utah. Editor’s Note: For related articles, check out the archives at www.podiatrytoday.com.

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By Douglas Stoker, DPM
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