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Diabetic Shoes

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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:

--- Quote from: PMRNC on June 25, 2014, 06:15:07 PM ---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?

--- End quote ---

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.

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