Diabetic Shoes

[Ckilolo44@gmail.com]

Medicare isn't paying the claims for these items.  Does anyone know why?
We have the LMN.

[PMRNC]

They pay for one pair/insert, must be prescribed by one of following:     A podiatrist, orthotist, prosthetist, or pedorthist.
 http://www.medicare.gov/coverage/therapeutic-shoes-or-inserts.html

Do you have a specific denial on the EOMB?

[kristin]

1.Does your provider have a supplier number/contract with the DMERC insurance contractor for your region? If not, you will not be paid.

2. Are you submitting the claims to your DMERC insurance contractor, and not regular Medicare? If not, you will not be paid.

3. For diabetic shoes/inserts, you need to be a specific type of provider as pointed out by PMRNC. Is your provider one of those types? If not, you will not be paid.

4. If they are, how did you bill the claim? Did you have the proper modifiers and diagnoses? Was it one calender year since the patient last got shoes/inserts? Do you have a CMN and tx note from the doctor treating the patient for diabetes on file, as well as submitting the claim with the LDS and the referring provider info?

Need more info to help you at this point. Medicare DMERC is heavily auditing diabetic shoe claims, and the amount of documentation and claim info needed is ridiculous, so anything you can tell us will really help.

[Michele]

They pay for one pair/insert, must be prescribed by one of following:     A podiatrist, orthotist, prosthetist, or pedorthist.
 http://www.medicare.gov/coverage/therapeutic-shoes-or-inserts.html

Do you have a specific denial on the EOMB?

Actually I don't believe DPMs can order therapeutic shoes for diabetics.  I know it sounds crazy, but we know a supplier that had to return several thousand dollars to Medicare because they had been reimbursed for therapeutic shoes that were ordered by DPMs.  I see that the Medicare.gov site states that they can, but look at this one:  http://www.ngsmedicare.com/ngs/wcm/connect/26b2448045bb1c8f95b3dfd594896aeb/894_0812_therapeutic_shoes.pdf?MOD=AJPERES 

Very curious about this topic.

[shanbull]

Confusing.... This also says they can: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf

So does this: http://www.ngsmedicare.com/ngs/wcm/connect/516be9804eb21a80a72abf79abff8e81/SE1305+Revised.pdf?MOD=AJPERES&CACHEID=516be9804eb21a80a72abf79abff8e81

Maybe there's an LCD for specific jurisdictions where this is not the case?

Edit: Michele, for some reason I can't open the NGS PDF you linked. Can you open the one I posted?

Edit again: Found this buried in an LCD from the MAC for for DMEPOS Jurisdiction B (Illinois/Indiana/Kentucky/Michigan/Minnesota/Ohio/Wisconsin):
"The supplier must obtain a signed statement from the physician who is managing the beneficiary’s systemic diabetes condition (i.e., the certifying physician) specifying that the beneficiary has diabetes mellitus, has one of conditions 2a-2f listed in the related Policy Article, is being treated under a comprehensive plan of care for his/her diabetes, and needs diabetic shoes. The certifying physician must be an M.D. or D.O and may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist. The "Statement of Certifying Physician for Therapeutic Shoes" form (see LCD Attachments section below) is recommended. Whatever form is used must contain all of the elements contained on the recommended form attached to this LCD. This statement must be completed, signed, and dated by the certifying physician. A new Certification Statement is required for a shoe, insert or modification provided more than one year from the most recent Certification Statement on file."

Link: http://www.ngsmedicare.com/ngs/portal/ngsmedicare/l27040/!ut/p/a1/tZLNboMwEIRfhQvHyov5MRxR2qRJSyqFRgEulWsMcQSGgBW1ffoCSaReCO2hvq39jXZnxyhBEUokPYmcKlFJWvR14rzB2rz357YFENo2LB9gQ4KQYLCMDoh7YBXOzkDgASx9J5wvFmC-rO2betec0uMp_Q4lKGFS1WqPYpm3JU8Fow1nlVRcKh1-3OnAqhNvaM61lCvelEIOPnU4E4VWV4VgnxrrlLzRocAELOg71J0o5a3I5VAxkaIYgILrAlgpUIIZ9TxqexkjhkHeDRPsq7eR48PUbgdvE9u9DeArMD5D3A1JRqd4wij8g-PVL76LOByPid-F1if0oVD0T6l1rXATzIK8T0_t74TMKhRdHutyuy3dQ_bsbB6_XrNy57b-NwTcmO0!/dl5/d5/L2dBISEvZ0FBIS9nQSEh/

So podiatrists can order, but the Certification of Medical Need statement needs to come from an M.D. or D.O. I guess.

[Ckilolo44@gmail.com]

The doctor is a Podiatrist and yes  we've been billing to the DMERC with
the correct modifiers.  The payments were coming in just fine, but about a year ago
we've been getting rejections.   I will have to get the EOB to see what specifically it says.
I will also check to see if it's the 1st or 2nd pair.

[Michele]

Shanbull, I was able to open all of your links.

[kristin]

Podiatrists can definitely be the ordering physician, but as shanbull points out, they cannot be the doctor who signs the Certifying Physician Statement, that has to be the MD/DO managing the diabetes. The treatment note that needs to be on file documenting the criteria the patient has that necessitates the shoes/inserts can be from either the DPM or MD/DO, but if it is from the DPM, it has to be signed/dated by the MD/DO signaling their concurrence with what the DPM has listed as the criteria.

I am curious to see what the denial reason is for these claims, because I think I have an idea already what is going on, and want to see if I am correct. A podiatrist I bill for remotely had a similar issue, starting about a year ago, and it turned out that DMERC was prepayment auditing every claim for shoes/inserts, but for some reason, the podiatrist either never got the prepayment audit request, or  sometimes they did, and staff filed it away without saying anything. So it wasn't until the claims denied after the paperwork the DMERC requested wasn't received that I figured out what was going on.

Then again, it could be something much easier to fix. LOL!

[Michele]

Thanks for clarifying that.  I now see what this other provider was faced with.  The shoes/inserts were ordered by the DPM.  That was ok, but they needed to get the MD that was overseeing the patient to sign off on the CMN.  That is where they went wrong!  Well, it wasn't my problem, I just wondered what had happened.  Now I know!   

[Ckilolo44@gmail.com]

Ok, I want to be sure I have a clear understanding on the solution; the Primary doctor needs to sign off on CMN, not the Podiatrist?
Also, there have been no EOBs from Medicare on the accounts where Medicare was billed for the shoes. 

[kristin]

Yes, the CMN must be signed by an MD or a DO only...NOT a DPM. The purpose of the CMN is for the MD/DO that is actually managing the patient's diabetes(something a DPM does not do, it is out of their scope of practice) to say that the patient has diabetes, and also has certain criteria that qualifies them to have the shoes/inserts.

As for why your DME-MAC is not sending you EOB's....I have no idea. The claims are for sure being sent to the DMERC, and not to the regular MAC, right? For instance, my DME-MAC and my regular MAC are both NGS...but the claims go to two different addresses.

[shanbull]

Ok, I want to be sure I have a clear understanding on the solution; the Primary doctor needs to sign off on CMN, not the Podiatrist?
Also, there have been no EOBs from Medicare on the accounts where Medicare was billed for the shoes.

Yes to the first question. In the case of no EOB's I would call the DMERC and make sure the claims were received in the first place. Usually no EOB means something went wrong with the claim submission. Are you submitting the claims on paper or electronically? We submit electronically and the only time we don't get an EOB is if the claim was stopped at our clearinghouse, in which case we have to check with the clearinghouse to see why the claim was rejected from processing altogether.

[Ckilolo44@gmail.com]

Yes, we are submitting electronic claims.  I tried calling DME but our PTAN is incorrect so I can't get any information until that's corrected.
After that, I will check the clearing house to see why no rejections on these claims. 
Thanks a bunch!

[kristin]

Which PTAN did you give them? Because the PTAN for DME is not the same one for regular Medicare. So it could be that it isn't incorrect, you just need the right one when you call. If you have the paperwork from DME when you initially enrolled and were approved as suppliers, the PTAN should be on that paperwork from them.