Who Qualifies
The patient must have diabetes and at least one qualifying condition documented in the medical record.
- Previous amputation of the other foot or part of either foot
- History of foot ulceration of either foot
- History of pre-ulcerative calluses of either foot
- Peripheral neuropathy with evidence of callus formation of either foot
- Foot deformity of either foot
- Poor circulation in either foot
The Certifying Physician
The certifying physician is an MD or DO who manages the patient's diabetes. That physician must have an in-person visit with the patient to discuss diabetes management within six months before the shoes are delivered, and sign the certification statement on or after that visit and within three months before delivery. The qualifying foot condition must be documented in the certifying physician's record, either personally or by reviewing, initialing and dating another practitioner's note. The signed statement alone is not enough.
Quantities Per Calendar Year
- One pair of depth shoes and three pairs of inserts, or
- One pair of custom-molded shoes (including inserts provided with them) and two additional pairs of inserts
Billing The Items
The supplier bills the DME MAC using the HCPCS codes in the therapeutic shoe policy (LCD L33369), such as A5500 for depth shoes and A5512 to A5514 for inserts, with the KX modifier once all coverage requirements are met. Claims without KX are denied as non-covered. The supplier must also perform an in-person evaluation before selecting the items and document an objective fit assessment at delivery.
Frequently Asked Questions
- Can a podiatrist be the certifying physician?
- No. The certifying physician must be an MD or DO managing the diabetes. A podiatrist can evaluate the foot, prescribe the shoes and supply them, and the podiatrist's note can be used if the certifying physician reviews, initials and dates it.
- Are shoes covered every year?
- The quantity limits reset each calendar year, but each year's items need current documentation meeting the visit and certification timing rules.
Billing Support For This Specialty
Physicians Professional Billing Services, Inc. has billed wound care, surgical and procedural specialties since 1998, across every Medicare Part B MAC jurisdiction.
Primary Sources
This page is general information about billing and coverage rules and is not legal, coding or reimbursement advice for a specific claim. Coverage policies change; confirm current requirements with CMS and the applicable Medicare Administrative Contractor.