More than likely, you’re feeling overworked and overwhelmed by the basic procedures of patient care and business management. Or, maybe you finally feel like you’ve settled in to your routine and things are running smoothly. Either way, why would you seek to add an extra program to your business? Won’t that just require more staff, more education, and more hassle? Besides, you’re not a shoe store, right?
Offering your patients diabetic shoes is not turning your business into a shoe store. Think of it in terms of medications, products, or services you already offer your patients to help them achieve their best health. And this product comes with some unique revenue-boosting bonuses!
Thanks to the Medicare Therapeutic Shoe Bill, patients who meet certain criteria can receive one pair of therapeutic shoes and three pair of inserts annually, usually with minimal or no cost to them. Medicare reimbursement rates in general are subject to frequent change (often lower than previous years), but the average reimbursement amount for a qualified diabetic shoe and insert patient has increased steadily over the last several years. Now think about how many diabetic or otherwise qualifying patients you might have and do the math!
On January 1, 2022, Medicare increased the amount it pays for diabetic shoes.
While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Shoes (A5500): $77.80/ea; $155.60/pair
Heat Molded inserts (A5512): $31.73/ea; $190.38/ 3 pair
Custom inserts (A5513/A5514): $47.35/ea; $284.10/ 3 pair
Depth shoes w/3 pair heat molded inserts: $345.98
Depth shoes w/3 pair custom molded inserts: $439.70
Medicare (Part B) Reimbursement Guidelines
Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met:
1. The beneficiary has diabetes mellitus and
2. The certifying physician has documented in the beneficiary's medical record one or more of the following conditions:
a. Previous amputation of the other foot, or part of either foot, or
b. History of previous foot ulceration of either foot, or
c. History of pre-ulcerative calluses of either foot, or
d. Peripheral neuropathy with evidence of callus formation of either foot, or
e. Foot deformity of either foot, or
f. Poor circulation in either foot; and
3. The certifying physician has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes.
4. For claims with dates of service on or after 01/01/2011, the certifying physician must:
o Have an in-person visit with the beneficiary during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
o Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.
5. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-person evaluation of the beneficiary.
6. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results. A beneficiary’s subjective statements regarding fit as the sole documentation of the in-person delivery does not meet this criterion.
If criteria 1-5 are not met, the therapeutic shoes, inserts and/or modifications will be denied as non-covered. When codes are billed without a KX modifier, they will be denied as non-covered.
i. Personally, document one or more of criteria a – f in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or
ii. Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a – f.
a. One pair of custom molded shoes (A5501) (which includes inserts provided with these shoes) and 2 additional pairs of inserts (A5512 or A5513); or
b. One pair of depth shoes (A5500) and 3 pairs of inserts (A5512 or A5513) (not including the non-customized removable inserts provided with such shoes).
To look up current reimbursement rates for specific HCPC codes based on the most recent Medicare Fee Schedule, go to: https://www.dmepdac.com/dmecsapp/do/search.