Skip to Main Content

Print | Bookmark | Font Size: + | –

Therapeutic Shoes

Documentation Requirements Include:

  1. Prescribing physician's detailed written order
  2. Completed, signed and dated statement from the certifying physician (physician managing the beneficiary's systemic diabetes condition) specifying that the beneficiary has diabetes and:
    1. Previous amputation of the other foot, or part of either foot, or
    2. History of previous foot ulceration of either foot, or
    3. History of pre-ulcerative calluses of either foot, or
    4. Peripheral neuropathy with evidence of callus formation of either foot, or
    5. Foot deformity of either foot, or
    6. Poor circulation in either foot, and is being treated under a comprehensive plan of care for his/her diabetes, and needs diabetic shoes.
  3. Clinical evaluation, performed by the certifying physician within six (6) months prior to delivery, that addresses the beneficiary's diabetes management.
  4. Relevant medical records where the certifying physician either personally documented that the beneficiary met one or more of criteria 2a - 2f or obtained documentation from another clinician documenting the beneficiary met one or more of criteria 2a - 2f and the certifying physician indicated agreement with the information by initialing and dating the record
  5. Supplier in-person evaluation conducted prior to selection of items that documents an examination of the beneficiary's feet with a description of the abnormalities that will need to be accommodated by the shoes/inserts/modification
  6. In-person visit, at the time of delivery, which assesses the fit of the shoes and inserts with the beneficiary wearing them
  7. Delivery documentation with the beneficiary's name and address and the description of the items provided
  8. Any other pertinent records.
  9. ABN on file should be submitted with other requested documentation.

Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify that the patient's condition meets coverage criteria for therapeutic shoes for persons with diabetes.

The source of these records may be a physician's office, hospital, nursing home, home health agency, wound clinic, etc. evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier.

 

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved