revised december 3, 2015 | © copyright 2015. · 2017-11-28 · title: dme cert task force webinar:...

CERT Diabetic Shoe Errors: The DME CERT Outreach and

Education Task Force Responds DME CERT Outreach and Education Task Force National Diabetic Shoe Webinar, December 2015


Therapeutic Shoes for Persons with Diabetes

CERT Errors


Diabetic Shoe Error Analysis 2014 Preliminary CERT Errors 2015 Preliminary CERT Errors

No documentation of diabetic mgmt No documentation of diabetic mgmt

Altered documentation Altered documentation

Signature and/or legibility issues Signature and/or legibility issues

Detailed written orders Detailed written orders

No medical records within six months Foot examination documentation issues

Statement of Certifying Physician issues In-person exam prior to fitting/delivery

Fitting and delivery documentation issues Fitting and delivery documentation issues


Diabetic Shoe CERT Errors: Four Main Areas Detailed written orders (invalid, written after delivery, missing elements)

Medical records from the Certifying Physician (diabetic management)

Foot examination (incomplete records from certifying or prescribing physician corresponding to foot issues on Statement)

In-person exam at ordering and fitting at delivery (incomplete records from diabetic shoe supplier)


Defined Roles of Practitioners and Suppliers of Diabetic Shoes


Certifying Physician Certifying physician provides the medical care for and manages the

beneficiary’s systemic diabetic condition

• Certifying physician must be an M.D. or D.O.

• Certifying physician cannot be a podiatrist, physician assistant, nurse practitioner or clinical nurse specialist

• Certifying physician may not furnish the footwear unless he/she practices in a defined rural area or a defined health professional shortage area

• Certifying physician completes and signs a Statement of Certifying Physician


Prescribing Physician Prescribing physician writes the orders for the therapeutic shoes,

modifications, and inserts

• May be a Podiatrist (DPM), M.D., D.O., Physician Assistant, Nurse Practitioner, or a Clinical Nurse Specialists

• Must be knowledgeable in fitting diabetic shoes and inserts

• Prescribing physician can be the supplier


Supplier Specifications Supplier is the entity that furnishes the diabetic shoes, modifications, and/or

inserts and bills the Medicare program

• Supplier may be a podiatrist or other qualified individual

• Supplier measures feet prior to ordering shoes

• Supplier confirms fitting of diabetic shoes at delivery

• Prescribing physician may be the supplier


Coverage Criteria for Diabetic Shoes


Overview of Coverage Criteria 1. Beneficiary has diabetes mellitus

2. Certifying physician has documented foot condition(s)

3. Certifying physician is treating the beneficiary’s systemic diabetic condition

4. Supplier conducts in-person evaluation with beneficiary prior to selecting shoes and inserts

5. At delivery, supplier conducts objective assessment of fit of the shoes and inserts and documents the assessment


Physician’s Orders for Diabetic Shoes


Detailed Written Orders The Detailed Written Order (DWO) must include:

Beneficiary’s name

Physician’s name

Date of the order

Detailed description of the shoes and inserts

The signature of the ordering practitioner

Signature date


Detailed Written Orders Must be signed/dated by physician

• Must be legible

Faxed, photocopied, electronic, or pen & ink orders are acceptable for claim submission

Must be kept on file by supplier

Signature and Date stamps are not acceptable on orders

• Exception: Rehabilitation Act of 1973 in the case of an author with a physical disability


Detailed Written Orders New detailed written orders are required every calendar year when the

beneficiary gets new shoes (Therapeutic Shoes for Persons with Diabetes is a calendar year benefit)

New detailed written orders are required when diabetic shoes are replaced during a calendar year (loss or irreparable damage)

No new orders are not required for replacement of insert or modification within one year of the detailed written order on file

If the supplier is the prescribing physician, a separate order is not required, but information must be present in the beneficiary’s record


Diabetic Shoes Medical Records and Diabetic Management


Certifying Physician Manages the Diabetic Condition Therapeutic shoes, inserts, and/or modifications to therapeutic shoes for

persons with diabetes are covered if:

1. Beneficiary has diabetes mellitus

– ICD-9 diagnosis codes for dates of service prior to October 1, 2015

– ICD-10 diagnosis codes for dates of service on or after October 1, 2015


Certifying Physician Manages the Diabetic Condition Certifying physician (MD or DO) who is managing the patient's systemic

diabetes condition certifies the following:

• That he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and;

• The beneficiary has at least one of the six foot conditions

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; and

• That the beneficiary needs diabetic shoes


Certifying Physician Manages the Diabetic Condition For claims with dates of service on or after January 1, 2011, the Certifying

physician must:

• Have an in-person visit with the beneficiary during which diabetes management is addressed within six (6) months prior to delivery of the shoes/inserts; and

• Sign the Statement of Certifying Physician on or after the date of the in-person visit and within three (3) months prior to delivery of the shoes/inserts


Diabetic Shoes Foot Examination


Foot Examination for Diabetic Shoes For claims on or after January 1, 2011, there must be a foot examination

conducted that outlines the certifying physician has either:

• Personally documented one or more of the foot problems in the medical record of an in-person visit within six (6) months prior to delivery of the shoes/inserts and prior to or on the same day as signing the Certification Statement; or

• Obtain, initial/sign, date and indicate agreement with the information from the medical records of an in-person visit with a podiatrist, other M.D. or D.O., PA, NP or CNS that is within six (6) months prior to delivery of the shoes/inserts and that documents the beneficiary is experiencing issues with one or more of foot problems noted


Foot Examination for Diabetic Shoes The medical record should contain, where applicable:

• Notes outlining amputation(s)

• Foot deformities

• Circulation issues

• Peripheral neuropathy and calluses

• History of ulcerations or pre-ulcerative calluses

• Some practitioners use templates – auditors expect to see more than simply checked boxes or circled items. The report should be specific to that individual beneficiary’s foot problems


Diabetic Shoes Supplier In-Person Evaluation


Supplier In-Person Evaluation for Diabetic Shoes When selecting the appropriate shoes and inserts for the beneficiary, the

supplier must conduct an in-person evaluation. This evaluation must include the following:

• An examination of the beneficiary’s feet with a description of the abnormalities the shoes and inserts will accommodate

• For all shoes, measurements of the beneficiary’s feet

• For custom molded shoes and inserts, there must be impressions, casts, or CAD-CAM images of the beneficiary’s feet used in creating positive models of the feet

• All of this information must be in the beneficiary’s record. If the prescribing physician is the supplier, the information may be in one record


Supplier In-Person Evaluation for Diabetic Shoes At the time of delivery, the supplier must conduct an in-person evaluation

while the beneficiary is wearing the shoes/inserts and document the proper fit of the shoes

• Notes of an objective assessment indicating how the shoes accommodate the beneficiary’s foot problem must be noted

• Beneficiary subjective statements such as “shoes fit good” will not meet this LCD requirement

• As a reminder, the date of service billed to the Medicare program is the date the beneficiary received the shoes/inserts. The quantity of shoes and inserts must be on the delivery ticket


Questions?


Thank You! Thank you for participating in this DME CERT Outreach

and Education Task Force presentation.


Disclaimer The DME CERT Outreach and Education Task Force consists of representatives from each of the DME MACs and is independent from the CMS CERT Team and CERT Contractors, who are responsible for the calculation of the Medicare Fee-for-Service Improper payment rate.

The DME CERT Outreach and Education Task Force has produced this material as an informational reference for providers furnishing services in our contract jurisdictions. The DME CERT Outreach and Education Task Force employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov.


http://www.cms.gov/

revised december 3, 2015 | © copyright 2015. · 2017-11-28 · title: dme cert task force webinar:...

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