If provider who prescribed shoes has documented one or more of conditions 2A-2F and certifying physician has dated/initialed and indicated agreement with those records prior to signing Certification Statement, criteria 2 will be met.
INSTRUCTIONS TO RECEIVE THERAPUTIC FOOTWEAR FOR DIABETICS FROM MEDICARE THE FITTING PLACE, INC 1440 22ndSTREET WEST DES MOINES, IA 50266 PHONE-515-225-3043 FAX-515-225-0184
Coverage of therapeutic shoes for persons with diabetes is based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”) and coverage of therapeutic shoes and inserts under the Therapeutic Shoes for Individuals with Diabetes benefit (Social Security Act §1861(s)(12)).
The Centers for Medicare & Medicaid Services (CMS) has recently provided guidance to the DME MACs about the delegation of certifying physician (MD or DO) comprehensive management of diabetes responsibilities to nurse practitioners (NP) and physician assistants (PA) prescribing therapeutic shoes and inserts for persons with diabetes.
The doctor who treats your diabetes must certify your need for therapeutic shoes or inserts. A podiatrist (foot doctor) or other qualified doctor must prescribe the shoes or inserts, and you must get the shoes or inserts from one of these: A podiatrist. An orthotist.
1. Detailed written order (prescription). Include space for prescribing shoes (A5500), the quantity of custom inserts (A5513) or quantity of prefab heat-moldable inserts (A5512). This must be dated within six months of dispensing shoes.
Therapeutic or Diabetic Shoes are shoes that offer support and protection for your feet and reduce the risk of skin breakdown, primarily in cases of poor circulation, neuropathy and foot deformities. The interior of the shoes are usually made with soft material and with no protruding stitching.
HCPCS code A5500 for For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi- density insert(s), per shoe as maintained by CMS falls under Diabetic Footwear .
Therapeutic shoes for diabetics are not durable medical equipment (DME) and are not considered DME nor orthotics, but a separate category of coverage under Part B. In situations in which an individual qualifies for both diabetic shoes and a leg brace, these items are covered separately.
Diabetic shoes and inserts are covered under Medicare, Medicaid, and most insurance policies as long as certain criteria are met and your physician completes a therapeutic shoe form. Generally, if you have met your deductible and qualify for shoes, Medicare will pay 80% of the cost.
For the most part, Medicare does not cover orthopedic or inserts or shoes, however, Medicare will make exceptions for certain diabetic patients because of the poor circulation or neuropathy that goes with diabetes.
Medicare covers the cost of orthopedic shoes for people with diabetes who have an additional foot deformity or neuropathy. The payment should be processed by your healthcare practitioner.
According to the Centers for Medicare and Medicaid Services, HCPCS code L3000 (Foot insert, removable, molded to patient model, UCB type, Berkeley Shell, each) is not payable by Medicare. HCPCS code L3000 is to be used for custom made orthotics (shoe inserts) and not for over the counter shoe inserts.
HCPCS Code L3030 L3030 is a valid 2022 HCPCS code for Foot, insert, removable, formed to patient foot, each or just “Foot arch support remov prem” for short, used in Lump sum purchase of DME, prosthetics, orthotics.
L3010: Prescription Custom Fabricated Foot insert, each, removable. This type of device is fabricated from a three dimensional model of the patient's own foot (e.g. cast, foam impression, or virtual true 3-D digital image).
While these definitions may be a bit wordy or confusing, the main difference relates to the model that the orthotics are manufactured from – physical model (A5513) vs digital, CAD-CAM model (A5514).
The Certifying Physician is a doctor of medicine (MD) or a doctor of osteopathy (DO), enrolled as a Medicare provider, who is responsible for diagnosing and treating the beneficiary’s diabetic systemic condition through a comprehensive plan of care (POC).
Coverage of therapeutic shoes for persons with diabetes is based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”) and coverage of therapeutic shoes and inserts under the Therapeutic Shoes for Individuals with Diabetes benefit (Social Security Act §1861(s)(12)). In addition, there are specific statutory payment policy requirements that must also be met.
A provider other than a MD or DO can provide order for shoes and do foot exam with Certifying Physician dating, initialing and indicating agreement with those records but MD or DO must be treating beneficiary for their diabetic condition and they must be seen within six months prior to delivery of shoes.
When suppliers are reviewing physician's medical records for a comprehensive plan of care, physician must have documented in those notes what is occurring with beneficiary's diabetes and how are they managing their diabetes. This will be different for every beneficiary and their condition.
It is not specific as to where agreement exists but must be included on actual medical record. Certifying physician is not required to document a foot exam and/or need for diabetic shoes in his/her medical record when they are NOT prescribing physician.