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 shoe modifications to qualifying Medicare Part B patients with diabetes. The Centers for Disease Control has estimated that 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 patients' systemic diabetic condition is called the certifying physician. The certifying physician must state that the patient has diabetes mellitus, indicate 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 amount for one pair of depth shoes and three pairs of inserts OR one pair of custom molded shoes (which include 1 pair of inserts) and two additional pairs of inserts. Also: 1) a shoe modification can be substituted in lieu of a pair of inserts, 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 the patient.
Start the Process, prosthetist to have prescription filled? For the qualified patient to receive this benefit, the certifying physician (M.D. or D.O.) must review and sign a "Statement of Certifying Physician for Therapeutic Shoes" form 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. For traditional fee-for-service Medicare patients, the supplier will keep the documentation on file and submit the claims to Medicare on behalf of the patient. NOTE: Suppliers may not be able to dispense or submit claims for devices for 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.
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 patients' 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.