Physician Information on Medicare Benefit for Therapeutic Footwear for Diabetics
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Physician Information on Medicare Benefit for Therapeutic Footwear for Diabetics

Physicians have a unique and unparalleled opportunity to help qualified diabetic patients protect their feet, simply by filling out one short form that takes less than two minutes to complete.

In 1993, Congress amended the 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 law recognizes that footwear can help prevent lower-limb amputations in long-term diabetic patients.

The Centers for Disease Control has estimated that 82,000 lower-limb amputations due to diabetes occur annually (2003 figures).  Experts agree that most would have been preventable with an appropriate foot care program including footwear that is properly fit to the patient.

How Patients Qualify

The physician (M.D. or D.O.) who is managing the patient's systemic diabetic condition must certify that:

1. The patient has diabetes mellitus (ICD-9 diagnosis codes 249.00-250.93)

2. The patient has one or more of the following conditions. Physician must indicate which condition(s), for which the physician maintains documentation in his/her patient record.

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;

3. That he/she is treating the patient under a comprehensive plan of care for diabetes; and

4. The patient needs therapeutic shoes.

What Is Reimburseable

Within a given calendar year, the qualifying patient can receive 80% of the allowed amounts for:

* One pair of depth shoes and three pair of inserts OR

* One pair of custom molded shoes (including inserts) and two additional pairs of inserts.

In addition:

1) Separate inserts may be covered under certain criteria;

2) A shoe modification will be covered as a substitute for an insert; and

3) A custom molded shoe is covered when the patient has a foot deformity which cannot beaccommodated by a depth shoe.

How the Process Works

For qualified patients, this important preventive provision involves:

The Certifying Physician (the M.D. or D.O. managing the patient's systemic diabetic condition) must review, complete, sign and date the certifying physician's statement (see attached form, which can be photocopied). Physicians are expected to maintain this documentation in their patient files.  It is necessary that the Certifying Physician circle the condition that qualifies the patient for this benefit. AND

The Prescribing Physician (a podiatrist or other qualified physician knowledgeable in the modification and fitting of diabetic shoes and foot orthoses) must provide the patient with a footwear prescription (such as attached sample).

Once the patient has both the certifying statement and the footwear prescription, he/she can see a qualified pedorthist, orthotist, prosthetist, or podiatrist to have the prescription filled.  The supplier must submit the Medicare claim (Form CMS 1500 or electronic version) to the appropriate Durable Medical Equipment Regional Carrier (DMERC) for traditional Medicare patients*, keeping copies of the claim form in the patient's records with the original prescription and certifying physician's statement. *Suppliers may not be able to dispense or submit claims for these devices to managed care Medicare patients.

Physician Responsibilities:  Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. §13951(e)).  Medicare expects that the patient's medical records will reflect the need for the care provided and that the physician will maintain copies of the documentation he/she provides the dispenser in his/her patient records.  This documentation must be available to the DMERC upon request, even for the certifying and prescribing physicians.

Reimbursement Amounts

The Centers for Medicare & Medicaid Services (CMS) will reimburse 80% of the amount it designates as "allowable."  The reimbursement will go EITHER directly to the supplier (if the supplier accepts assignment) OR to the patient (if the supplier does not accept assignment).  NOTE:  Many dispensers do not accept assignment because they consider CMS's allowable rates too low to cover the appropriate materials and services.  This means that the total cost to the patient may be higher than the "allowable" amount.  In such cases, the patient is usually expected to pay in full, prior to receiving any Medicare reimbursement.

Effective January 1, 2002, covered inserts have been divided into two separate codes; one code for prefabricated, direct-formed inserts, molded to the patient's foot with an external heat source (i.e. heat gun); and another code for custom-molded, custom-fabricated inserts, molded from a model of the patient's foot.  Both inserts have the same allowable amount.

ICD-9 Codes

Because this benefit is available to diabetic patients only, an appropriate ICD-9 code (249.00-250.93) is required on the Statement of Certifying Physician.  All five digits are required on the Statement.

What Patients Can Expect

Dozens of manufacturers currently make shoes that can be termed therapeutic.  Styles and colors for these traditional and athletic shoes vary.  However, therapeutic footwear is by nature medical, and fitting it to the patient's foot requires special skills and care.  Medicare requires that this benefit be dispensed by a qualified supplier, which means a podiatrist, pedorthist, orthotist or prosthetist.

Pedorthics is the design, manufacture, modification and fit of footwear, including 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.)

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