Patient Information on Medicare Benefit for Therapeutic Footwear for Diabetics
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Patient Information on Medicare Benefit for Therapeutic Footwear for Diabetics*

In May 1993, Congress amended Medicare statutes to provide partial reimbursement for depth shoes, custom molded shoes, and shoe inserts or modifications to qualifying Medicare Part B patients with diabetes.  The Centers for Disease Control has estimated that many thousands of lower limb amputations due to diabetes occur annually – and experts agree that most are preventable with comprehensive foot care programs, including appropriate footwear that is properly fit.

How Patients Qualify

The physician (M.D. or D.O.) who manages the patient's systemic diabetic condition is called the certifying physician.  The certifying physician must state (see form on other side) that the patient has diabetes mellitus, indicate which one or more of the conditions which Medicare describes as placing the patient at risk, and state that the patient is being treated under a comprehensive plan of care for his/her diabetes and needs therapeutic shoes and/or inserts because of the diabetes.

What is Reimbursable

Within a given calendar year, the qualifying patient can receive 80% of the allowed amounts for one pair of depth shoes and three pairs of inserts (not including the non-customized removable

inserts provided with such shoes), OR one pair of custom molded shoes (which include 1 pair of inserts) and two additional pairs of inserts. Also: 1) shoe modifications can be substituted for an insert; and 2) custom molded shoes are only covered when the patient has a foot deformity that cannot be accommodated by a depth shoe. The inserts can be either direct-formed prefabricated inserts that have been heat molded OR custom-molded inserts that have been individually fabricated for you.

To Start the Process, Here Is What You Need to Do

For a qualified patient to receive this benefit, the certifying physician (M.D. or D.O.) must conduct an in-person visit with the patient during which diabetes management is addressed within 6 months prior to

delivery of the shoes/inserts, review and sign a "Statement of Certifying Physician for Therapeutic Shoes" prior to the dispensing of the devices. The prescribing physician (D.P.M., M.D. or D.O.) must complete an appropriate prescription. The patient can see a qualified pedorthist, orthotist, prosthetist, or podiatrist to have the prescription filled following an in-person evaluation by the supplier. For traditional fee-for-service Medicare patients, the supplier will keep the documentation on file and submit the claim to Medicare on behalf of the patient. NOTE: Suppliers may not be able to dispense or submit claims for devices to Medicare patients enrolled in Medicare managed care plans.

Patient Payment

The Centers for Medicare & Medicaid Services (CMS) will reimburse 80% of the amount it designates as "allowable,” and the patient is responsible for paying the dispenser/supplier a minimum of 20% of the total payment amount.  If the Medicare supplier does not accept assignment of the claim, the patient is responsible for the entire amount, and the patient will receive reimbursement directly from Medicare for 80% of the allowable amount.

NOTE:  Some Medicare suppliers may not accept assignment if the allowable amount is too low to cover the appropriate materials and services.  In these situations, the total cost to the patient may be higher than the allowable amount.  If so, the patient may be expected to pay the Medicare supplier in full before he or she receives reimbursement from Medicare.

The Pedorthic Dispenser/Supplier

Many manufacturers make shoes in varying styles and colors that can be termed therapeutic.  However, therapeutic footwear is by nature medical, and fitting it to the patient's foot requires special skills and care.  The pedorthic profession involves the design, fit, and modification of shoes and related foot devices to alleviate foot problems caused by disease, overuse or injury.  A credentialed pedorthist is a person who has met initial and continuing educational requirements, passed a comprehensive written exam and adheres to the standards of pedorthic practice.  A credentialed pedorthist also includes those pedorthists licensed by their state to practice pedorthics.

* This page contains generalized information on Medicare's Therapeutic Shoes for Diabetics benefit. One should always refer to their regional Jurisdictional DME MAC's Local Coverage Determination and Policy Article on the benefit for more detailed and up-to-date qualification and compliance information.

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