How To Complete Diabetic Shoe Medicare Forms Correctly

This author guides podiatrists through compliance paperwork for diabetic shoes that can help ensure payment for diabetic shoes.

The purpose of this article is to provide the recipe to create a documentation packet that will pass a Diabetic Shoe Pre-Payment Review. If you have ever seen Chopped on the Food Network, chefs compete for $10,000 as they try to make stellar dishes using surprise ingredients. Thankfully, the Diabetic Shoe Compliance paperwork is nothing like Chopped. The required documents are clearly defined beforehand without any surprise ingredients.   

Read the ingredients and follow the directions.  

Since the “freshness” of the ingredients is important, the lifespan of each document is included. Although there are nine ingredients, the recipe is simple.

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.

2. Statement of certification. Include space for asking the date of the last diabetic exam. The Statement of Certification must be dated within three months of dispensing shoes. (For the last diabetic exam, see item 3 below.)

3. Diabetes management exam. This is the diabetic exam progress note from the MD managing the patient’s diabetes. I recommend asking the MD only for the date of this exam. If the progress note is needed later for a pre-payment review, one can easily obtain the exam note. In my opinion, your referring MDs may object to copying their notes for every patient with diabetes. Giving you the date of the exam is much less time-consuming for the MD’s office. This must be an exam within six months of dispensing the diabetic shoes.

4. Diabetic foot exam performed by the DPM. Leave room for the MD’s signature.

5. Fitter’s note at time of measuring.

6. Packing slip of items purchased.

7. Fitter’s note at time of dispensing.

8. Authorization of payment. This is also known as a delivery receipt.

9. Advanced beneficiary notice (ABN).

Following The Directions For Completing The Paperwork

The DPM performs a diabetic foot exam. This can be an annual comprehensive diabetic foot exam and may give some detail on the conditions that qualify the patient for diabetic shoes. These conditions include: 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; or poor circulation. Please note that “pain” or just “neuropathy” does not qualify the patient for diabetic shoes.

For example, the foot exam may have a description of hammertoes, which foot, which toes, etc. (It may not be just checking off foot deformity on a pre-written form.) The DPM also examines the existing foot gear and counsels the patient on the benefits of wearing diabetic shoes with inserts.

On the bottom of the DPM diabetic foot exam, add the text:

MD/DO Acknowledgment of Diagnosis for Diabetic Shoes 

I have reviewed the diagnosis and agree with findings for:

Patient Name _______________

Birthdate ________________

I am including a copy of this diagnosis in the patient’s file

MD/DO Signature __________________________   Date _____________

Print MD/DO Name  __________________________

Please note that it must be a physician signature, not a stamp, and may not be completed by a PA or NP.

At the conclusion of the exam, the DPM can complete and print the detailed written order (#1), the statement of certification (#2) and diabetic foot exam (#4).    

Send the statement of certification (#2) and the foot exam note (#4) to the MD/DO (certifying physician) for a signature on each form. When returning these signed forms, make sure that the last diabetic exam is within six months of when the patient can receive the shoes. For example, if the last diabetic exam was 5½ months prior, you may not be able to dispense the shoes within the following two weeks. In that case, ask the patient to visit the MD/DO for diabetes management in order to receive the shoes.

The shoe fitter (MA or DPM) can meet with the patient before or after signing the statement of certification. The fitter’s note (#5) reiterates some items of concern from the prescription or the foot exam. Assuming that someone other than the DPM does the measuring, there should be some indication on this form that the fitter understands the foot issues for this patient. This form also includes measuring notes. Typically, these include: a) what size the patient thinks he or she wears; b) the description and wear pattern of the shoes the patient is wearing; c) Brannock Device or Ritz Stick measurements; d) any sample shoes patients try on for sizing; and e) the size and type of shoe you are ordering.

This note also includes whether the patient is to receive custom inserts; the type of impression (scan, foam or cast); or whether the patient needs heat-moldable inserts. Include any accommodations that are needed on the custom inserts if applicable.

Tips On Ordering And Dispensing Diabetic Shoes

If you have the MD/DO signatures on the foot exam and statement of certification, you may now order the shoes. When you receive the shoes and inserts, most vendors include a packing slip (#6). This is proof that you are dispensing Medicare qualified shoes and inserts, and not department store flip-flops.

The day you dispense the shoes, complete the dispensing note (#7). This note includes: a) a comment from the patient, such as “Shoes fit great!” and b) an objective comment from the fitter, such as “The shoes have enough room in the toe-box. I observed the patient walk without heel slippage.” This note also has a comment on the inserts, particularly if they are heat-moldable.

If the shoes are acceptable to both the fitter and the patient, the fitter then reviews the following with the patient: a) the supplier standards, b) break-in period, c) process and timing for changing inserts, and d) warranty period. The authorization of payment (#8) specifies that you discussed these items with the patient. This document states that the patient has received the items such as QTY= 2 (1 pair) of extra-depth shoes (A5500), and QTY=6 (3 pairs) of inserts (5512 or 5513). The patient is stating that you can bill Medicare and secondary insurance for the shoes and inserts. The document also states the return policy, warranty period and that you reviewed the supplier standards with the patient. The patient signs this page and includes his or her home address since this is where the products will be used. The shoe fitter then signs as the witness.

The last item is the advanced beneficiary notice (#9), which the patient signs. This specifies that the patient is responsible for the cost of the items if Medicare does not pay for it.

The patient happily takes the shoes home and now you can bill Medicare. The date-of-service is when the patient leaves your office with his or her shoes and inserts.  

Your packet for this shoe dispensing includes at least eight items: ingredients 1-9 with the exception of #3. However, you have the date of the diabetic exam note (#3). If you are unlucky enough to be randomly selected for a pre-payment review, simply call the MD/DO and ask for a copy of the exam note for the date (previously specified on the statement of certification). 

When you receive that note, add it to the packet in the correct place. (It always helps to put these pages in the correct order for Medicare.) You may want to add a table of contents to the package. Then fax the entire package to Medicare.

In Conclusion

By following this recipe, you may not win $10,000 from the Food Network but you will most likely not be chopped. Assuming that the dates and signatures are in order, and you have documented the patient’s foot condition, Medicare should pay this claim.

Mr. Chalfin has been helping podiatrists with the Diabetic Shoe Program for over 14 years. He has given lectures at many podiatry conferences, including the New York Podiatry Conference, the Western Foot and Ankle Conference, the American Podiatric Medical Association Region One meeting and others. Mr. Chalfin has disclosed that he is currently working with Anodyne Diabetic Shoes. He can be reached at MChalfin@cs.com or 877-379-3674.