Certifying Physician documents one or more of the following conditions in the patient's medical record (of Primary Care Physician) and certifies these conditions on the certifying statement:
Previous amputation of the other foot, or part of either foot; or
History of previous foot ulceration of either foot; or
History of Pre-ulcerative calluses of either foot; or
Peripheral Neuropathy with evidence of callus formation of either foot; or
Foot deformity of either foot; or
Poor circulation in either foot; and
Certifying Physician must either:
Personally document one or more of the above conditions in the medical record by in-person visit within 6 months prior to delivery of the shoes and prior to or same day as signing the Certification Statement; or
Obtain, initial/sign, date and indicate agreement with information from the medical records of all in-person visit with a Podiatrist, other M.D., D.O, P.A., N.P., or CNS that is within 6 months prior to delivery of shoes.
Certifying Physician must also certify:
Coverage criteria are met;
He/She is treating the patient under a comprehensive plan of care;
The patient needs diabetic shoes;
The in-person visit is within 6 months prior to delivery of shoes/inserts and Certification Statement within 3 months prior to delivery of the shoes.
Prior to selecting product, the supplier must:
Conduct an in-person evaluation documenting:
Examination of feet, description of abnormalities, accommodations required;
Measurement of feet;
Methodology utilized for custom molded inserts (cast, foam, other).
At time of delivery
Conduct and document all in-person visit with the patient:
Evaluations with patient wearing shoes;
Document shoes, inserts and modifications to fit properly.
Limited to one pair within one calendar year
Product Description: Pre-fabricated Diabetic Shoe with Custom or Heat Moldable Inserts
Product Treats: Diabetes
Product Utilization: Patient is ambulatory and has one of the following: 1. History of partial or complete amputation of the foot; 2. History of previous foot ulceration; 3. History of pre-ulcerative callus; 4. Peripheral neuropathy with evidence of callus formation; 5. Poor circulation. Custom Diabetic Inserts utilized when the following criteria are met: hammer toes, bunions, calluses, peripheral neuropathy, foot deformities Heat Moldable Inserts utilitized when Custom Inserts are not indicated Toe Filler utilized when amputation of toes 1-5, 1-2 or great toe
Manufacturer: Dr. Comfort, OrthoFeet or Pedors
Sizes: Refer to vendor for specific sizes, use measuring stick
Coding: A5500 - Pre-fabricated Diabetic Shoes. Billed as one pair A5512 - Heat Moldable Inserts - 3 pair A5513 - Custom Inserts - 3 pair L5000 - Toe Filler - billed as 1 unit ICD: 250.00 - 250.93 - Diabetes Mellitus 895.0 - 895.1 - Amputation of Toes/Use with Toe Filler
Required Documentation: Signed CMN prior to ordering shoes/inserts along with Nursing/Therapy/Physician Notes stating above diagnosis/conditions. If ordering Custom Inserts, must include description of why Custom Inserts are required on CMN in description section.
Adjunct Products: Trans Metatarsal Amputation Socks, L8417 must have TMA ICD: 895.0 - 895.1