In order to qualify for therapeutic shoes and inserts, certain qualifications must be met in order for a podiatrist to be reimbursed.
Patients who qualify for therapeutic shoes must have diabetic mellitus (ICD-9-CM codes 250.00 through 250.93) and have Medicare benefits. Other insurance carriers pay for these products as well and typically follow the Medicare guidelines.
Podiatry Coding: Qualifications
Patients must have documented conditions in their medical record in order to code and bill for shoes and they must have one or more of the conditions listed below:
• 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.
Patients may receive the following items per calendar year if they qualify:
• Three (3) pairs of Inserts – Custom or Pre-fabricated
• One (1) pair of Therapeutic shoes
Local coverage determination (LCD) specifies that certification must be obtained on a yearly basis and be signed by the medical doctor or doctor of osteopath who is treating the patient for diabetes. The podiatrist may indicate that he is the ordering physician but it is not enough sufficient data to meet national policy requirements. Both coders and billers should confirm the provider’s standards of operation prior to coding and billing for therapeutic shoes and inserts. If the podiatrist is consistent with following the guidelines, then an audit of every medical record will not be required. However, if documentation is lacking or inconsistent, the supplier should be advised regarding documentation requirements before coding or submitting a claim.
A written order for shoes and inserts must include specific details:
• Beneficiary name
• Description of supplies provided
• Narrative description, for example, diabetic shoes or the manufacturers and product name or number of the shoe or insert
• If custom fabricated, it must be indicated
• Any shoe modifications such as wedges or metatarsal bar must be listed
• Quantity dispensed
• Length of need
• Physician signature and date of signature
• Start date of the order if the signature date is different than the date of delivery
Bottom line, information should adequately be documented to match the shoes/inserts ordered.
When coding for these shoes and inserts, the first diagnosis code must indicate the patient has diabetes. Some codes, such as 250.00 and 250.01 must be used in conjunction with codes such as 736.7, 707.1 or 700.
The date of service is the date the shoes are dispensed to the patients.
The place of service is home or nursing facility.
HCPCs code A5500 is the code for the therapeutic shoe.
HCPCs code A5513 is used for custom molded inserts.
HCPCs code A5512 is the code for prefabricated heat molded inserts.
Modifier KX must be applied to indicate there is a statement of certification on file.
Modifiers LT or RT must also be added after the KX modifier.
When ordering a pair of shoes, multiply the per unit fee (one fee per shoe) times two (2) for a pair of shoes.
When ordering inserts you will charge per insert; so if you order three pairs of inserts, you multiply the single fee by six (6).
Enter a shoe on each line; however, I have seen insurances pay when coded as A5500-KX RT LT on one line.
As I mentioned in Part I of Foot Care coding and billing, there are a lot of guidelines to follow so it may not be a bad idea to keep a little cheat sheet on your desk when reviewing appropriate coding and billing procedures for podiatry. Each patient chart is individual, but there is a correct method to follow if you want to send out a clean claim and get paid quickly.
Related Podiatry Coding Content:
- Medical Terminology and Anatomy for Medical Coders
- Podiatry Coding- Part 1
- Podiatry Coding- Part 2
- AAPC : Podiatry coding certification