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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Therapeutic Shoes for
Persons with Diabetes
CERT Errors
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Revised December 3, 2015 | © Copyright 2015.
Diabetic Shoe Error Analysis
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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
Revised December 3, 2015 | © Copyright 2015.
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)
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Revised December 3, 2015 | © Copyright 2015.
Defined Roles of Practitioners and
Suppliers of Diabetic Shoes
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Coverage Criteria for Diabetic Shoes
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Physician’s Orders
for Diabetic Shoes
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Diabetic Shoes
Medical Records and Diabetic Management
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 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
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Diabetic Shoes
Foot Examination
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Foot Examination for Diabetic Shoes
 The medical record should contain, where applicable:
• Notes outlining amputation(s)
• Foot deformities
• Circulation issues (i.e., filament test)
• 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
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Revised December 3, 2015 | © Copyright 2015.
Diabetic Shoes
Supplier In-Person Evaluation
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Revised December 3, 2015 | © Copyright 2015.
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 CADCAM 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
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Revised December 3, 2015 | © Copyright 2015.
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
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Revised December 3, 2015 | © Copyright 2015.
Questions?
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Revised December 3, 2015 | © Copyright 2015.
Thank You!
Thank you for participating in this DME CERT Outreach
and Education Task Force presentation.
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Revised December 3, 2015 | © Copyright 2015.
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.
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Revised December 3, 2015 | © Copyright 2015.