DMEPOS Mini-Series #6 – Therapeutic Shoes for Diabetes

According to the CDC, there are more than 130 million adults with diabetes or pre-diabetes in the United States. Every 17 seconds someone is diagnosed. Noridian, Jurisdiction D, has been conducting Targeted Probe and Educate reviews of HCPCS code A5500, which is for therapeutic shoes. The quarterly results based on dollars from April through June 2022 show an improper payment rate of 52%! Every other claim for therapeutic shoes is denied due to lack of medical necessity and/or technical reasons. CGS also shows a pre-pay review Quarterly Status report for the same date range with an error rate of 62%! Please review the guidance below for the required documentation to bill and dispense therapeutic shoes, and what the top denial reasons are for recoupment.

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Coverage Criteria (1 through 5) must be met, or claim will be denied.

  1. Diabetic Condition
  2. Qualifying Foot Conditions – see link to Documentation Checklist under PAAS Tips
  3. Statement of Certifying Physician
  4. Supplier Evaluation
  5. Supplier Assessment of Fit

Documentation needed upon an audit:

  • Standard Written Order (SWO) – See our April 2021 Newsline for details
  • Statement of Certifying Physician – Must be signed and dated by the MD or DO managing the beneficiary’s diabetes. (Exceptions to MD/DO as the certifying physician are listed in the Local Coverage Determination (LCD))
  • Medical Records
    • Patient must have an in-person visit within 6 months prior to delivery that documents the management of diabetes and at least one of the qualifying foot conditions
    • The certifying statement by itself does NOT meet this requirement for the documentation in the medical record
  • Supplier Evaluation
    • Examination of the beneficiary’s feet describing any abnormalities that need to be accommodated by the shoes/inserts
    • Measurements of the feet
    • Impressions, casts, or images of the feet for custom molded shoes and inserts
  • Supplier Assessment of Fit
    • Must occur at the time of in-person delivery
    • Supplier must conduct an objective assessment of the fit of the shoes and inserts while the beneficiary is wearing them and document the results
      • For Example: no slippage of heals when walking, ample toe room, feet are supported by heel counter, inserts make contact with patient’s feet and fit inside the shoe properly
    • A beneficiary’s subjective statement regarding the fit does not meet this criterion as they may have neuropathy which prevents them from feeling if there is any rubbing or pinching
  • Proof of Delivery – Must include the address of the pharmacy, detailed description of item, quantity delivered, signature of beneficiary or representative and delivery date – billed date and delivery date must be the same

PAAS Tips:

Jennifer Ottman, CPhT