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“Check 7” Documentation for

Diabetic Shoes and Inserts

SEE MEDICARE GUIDELINES FOR COMPREHENSIVE DOCUMENTATION REQUIREMENTS

This document is meant to assist qualified healthcare professionals with the documentation required for Medicare reimbursement for diabetic shoes and inserts. It is not meant to be comprehensive. Providers are responsible for

understanding and adhering to all Medicare guidelines and requirements.

Updated 02/24/16

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“Check 7” - Overview

INCLUDED IN THIS DOCUMENT are samples and forms for the 7 main documents you need for Medicare reimbursed diabetic shoes and inserts. Use and retain these 7 documents in each patient’s file for best results in the event of an audit. The 7 documents are all listed in this simple check box:

You can use this document in several ways:

• Save a copy of the entire document for each patient.Open the original and “Save As” a new document, naming each with a unique name—such as the patient’s Record/ID #.

• Copy and Save individual pages out of this document.Each time you need to customize one for a new patient, simply open the page you need and customize it.

• Use the contents of these documents to create your own forms.

Doc 1 – Statement of Certifying Physician (SCP)

• Must be completed by the Primary Care Physician (PCP) treating the patient for his/her diabetes. Certifying physician must be an M.D. or a D.O.

• Must be signed within 3 months of the date the shoes and inserts are dispensed. • Certifying physician must have seen the patient within 6 months of the date the shoes and

inserts are dispensed to discuss the management of the patient’s diabetes.

TIP: EDUCATE PHYSICIANS AND GET YOUR PATIENTS INVOLVED– Some Primary Care Physicians may not always be very cooperative in completing this form if they don’t fully understand what you’re recommending. It is important to educate them on the benefits diabetic footwear provides for their patients. In some cases, you may find it helpful to get the patients involved by providing them with our “Dear Doctor” brochure, which they can give to their PCP to assist in obtaining the proper forms.

Doc 2 – Physician Notes on Qualifying Condition & Last Visit (No form for this)

Doc 2 requires you obtain a copy of the Primary Care Physician’s (PCP) notes documenting that they have:

1) seen the patient within the past 6 months to discuss the management of the patient’s diabetes 2) diagnosed the patient with one of the 6 qualifying conditions listed on the SCP

Medicare clearly provides TWO ways the qualifying condition can be documented by the PCP’s notes:

• The PCP can make the diagnosis and provide you with a copy of their patient notes, OR • Another qualified individual—such as a Podiatrist—can make the diagnosis and the PCP can

acknowledge it and include it in their patient file. As written in the Policy Article, the Certifying Physician must either:

• Personallydocumentoneormoreofcriteriaa–f(thequalifyingcondition)inthemedicalrecordofanin-personvisitwithin6monthspriortodeliveryoftheshoes/insertsandpriortooronthesamedayassigningthecertificationstatement;or

• Obtain,initial/sign,date(priortooronthesamedayassigningthecertificationstatement),andindicateagreementwithinformationfromthemedicalrecordsofanin-personvisitwithapodiatrist,otherM.DorD.O.,physicianassistant,nursepractitioner,orclinicalnursespecialistthatiswithin6monthspriortodeliveryoftheshoes/inserts,andthatdocumentsoneofmoreofcriteriaa–f.

TIP: MAKE IT EASY FOR THE PCP TO COMPLETE THE DOCUMENTS– Sending the SCP along with a simple cover letter explaining your request for their notes (sample included) makes it easy for the PCP to see everything at once, complete and sign the form, and fax the items back to you. As with the SCP, you may find it helpful to get the patient involved if you have difficulty getting the notes. Podiatrists may want to use a CDFE form to document the qualifying condition and have the PCP review it (search the internet for “CDFE form”).

“Dear Doctor” Brochure

Doc 3 – Prescription for Diabetic Shoes and Inserts

The Prescription for Diabetic Shoes may also be completed by the PCP). In addition to following all other Medicare guidelines for a prescription, please also note:

• Prescription must be dated within 6 months of the date shoes are dispensed • Prescription must include a description of items prescribed (extra-depth shoes, specify either

heat-moldable or custom fabricated inserts) • Prescription must include quantities prescribed (one pair of shoes, 3 pairs of inserts)

TIP: THE PRESCRIPTION MAY BE COMPLETED BY SOMEONE OTHER THAN THE PCP– A prescription may also be completed by a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.

Doc 4 – Documentation of Initial In-Person Fitting

Doc 4 may be used to document, as required by Medicare, that:

• The fitter met with the patient in person to do the initial fitting and perform a “diagnosis specific fitting and assessment”.

The fitter needs to assess the patient and document that the shoes and inserts they provide are consistent with the diagnosis. For example, if the diagnosis states the patient has a foot deformity, the fitter may note that they observed hammertoes and recommended a Lycra® shoe to accommodate.

Doc 5 – Documentation of In-Person Fitting at Time of Dispensing

Doc 5 may be used to document, as required by Medicare, that:

• The fitter met with the patient in person to dispense the shoes and ensure a proper fit

Doc 6 – Documentation of Exact Items Dispensed (Packing Slip)

Medicare requires you document an exact description of the items dispensed. While you may document this on other forms, the simplest way to do this to satisfy an auditor in the event of an audit is to:

• Keep a copy of the packing slip for the patient’s shoes and inserts.

Doc 7 – Authorization of Payment and Warranty

Doc 7 is to be completed and signed by the patient to:

• Confirm receipt of the shoes and inserts • Confirm receipt of DMEPOS Supplier Standards and Shoe Care Instructions (included in every

Dr. Comfort shoe box) • Authorize you to bill Medicare • Provide warranty information to the patient (see below)

IMPORTANT:Dr. Comfort does not dictate what you put on this form regarding warranty. Your warranty to the patient is up to you and is the agreement between you and the patient. The wording under “Patient Warranty Statement” on the form provided is one way we might suggest, but you should change this wording to reflect your company’s return policy.

Other Forms & Resources

Login to your account at www.drcomfort.com/accounts/login to access additional training materials, Medicare information, and educational literature you can share with your patients. Don’t have an account? Call our customer service team at (800) 556-5572 to get one set-up.

To download the original version of our “Check 7” Guide, login to your account and go to Medicare Information on the account Dashboard page. TIP: NOT SURE WHAT ICD-10 CODE TO USE? Click the link below or type it into your web browser to go to the CMS Medicare Coverage Database where you can look up the ICD-10 Codes for your region:

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52501&ver=8

STATEMENT OF CERTIFYING PHYSICIAN for Therapeutic Shoes

I am writing to request you complete the Statement of Certifying Physician below for the patient listed so that we may provide them with therapeutic shoes and inserts. In order to qualify for Medicare reimbursement, your certification that they meet the conditions listed below is required. Per Medicare: It is important to note that even though you may complete and sign a form attesting that all of the coverage

requirements have been met, there also must be documentation in your records to indicate that you are managing the patient’s diabetes and that one of the conditions listed below is present. If requested by the

supplier, you must provide copies of those records. (Robert D. Hoover, Jr., MD, MPH, FACP, Medicare Director, CIGNA, Jurisdiction C, February 2009)

Patient: Record/ID #: 1) This patient has diabetes mellitus: Type II Type I (ICD-10 Code(s): ) 2) This patient has one or more of the following conditions (check all that apply):

History of partial or complete amputation of the foot History of previous foot ulceration History of pre-ulcerative callus Peripheral neuropathy with evidence of callus formation Foot deformity Poor circulation

3) I am treating this patient under a comprehensive plan for care of his/her diabetes and the date of their last office visit during which we addressed their diabetes management was:

4) This patient needs special shoes (depth or custom-molded) because of his/her diabetes. 5) This patient needs shoe inserts (heat-molded or custom fabricated) because of his/her diabetes. Physician Signature: Date: Physician Name: NPI #: Physician Address: PLEASE FAX BACK TO:

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Date:

Patient:

D.O.B.:

Re: Diabetic Footwear Documentation Request

Dear

I am writing to request your assistance in providing the above patient with diabetic footwear, as provided under the Therapeutic Shoes for Persons with Diabetes Act (TSPD). In order to qualify for Medicare reimbursement, your certification that they meet certain conditions is required, as well as a prescription for diabetic shoes and inserts. I am asking you to please review and complete the attached forms, as follows:

1) STATEMENT OF CERTIFYING PHYSICIAN • COMPLETE, SIGN AND DATE • Please check appropriate items, based on your diagnosis.

2) COPY OF YOUR PATIENT NOTES INDICATING:

1. The patient has one of the six Qualifying Conditions listed on The Statement of Certifying Physician, AND

2. The date of last visit to discuss the management of the patient’s diabetes This is required by Medicare

3) PRESCRIPTION FOR DIABETIC SHOES AND INSERTS • COMPLETE, SIGN AND DATE

4) FAX THESE BACK TO ME AT:

Please do not hesitate to call me at if you have any questions.

I greatly appreciate your assistance in serving the needs of this patient.

Sincerely,

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PRESCRIPTION for Diabetic Shoes and Inserts

Patient Name: Record/ID #:

Date of Birth: Today’s Date:

Check all that apply:

Diabetes Mellitus Amputation(s) Ankle Instability Hammertoe(s) Charcot Deformity Drop Foot Bunion(s) Fasciitis Posterior Tib. Disorder Ulcer(s) Edema Peripheral Vascular Disease Callus(es) Corn(s) Neuropathy

The patient requires:

Diabetic Footwear, non-custom (A5500) – 1 pair (unless otherwise indicated)

With (select one):

Non-custom, heat moldable inserts (A5512) – 3 pairs (unless otherwise indicated)

Custom molded inserts (A5513) – 3 pairs (unless otherwise indicated)

Lesions requiring offloading: L 1 2 3 4 5

R 1 2 3 4 5

Toe filler (L5000)

Comments:

Clinician Name:

Signature: Date:

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DOCUMENTATION of INITIAL

IN-PERSON FITTING

Patient Name:

Record/ID #:

Met with patient in-person on:

At the following location:

Fitter’s Initials (below):

Observation of feet (refer back to Physician if any open sores are evident):

Diagnosis-specific issues from prescription to be considered:

Recommendations / Sizing (attach separate fitting form, if used): Fitter’s Signature Fitter’s Name (Printed) Date Signed

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DOCUMENTATION of IN-PERSON FITTING at TIME of DISPENSING

Patient Name:

Record/ID #:

Met with patient in-person on:

At the following location:

Fitter’s Initials (below):

Patient comments regarding fit:

Fitter’s comments regarding fit and any accommodations made at time of dispensing:

Follow-up instructions to patient and plan of care notes: Fitter’s Signature

Fitter’s Name (Printed)

Date Signed

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HEAT-MOLDABLEINSERTSMOLDEDTOPATIENTATTIMEOFDISPENSING.

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AUTHORIZATION of PAYMENT and WARRANTY

Patient Name:

Record/ID #:

Delivery Address:

I have received individual (enter “2” for a pair) Dr. Comfort (style: ) “extra-depth” shoes and (choose one below):

individual (enter “6” for 3 pairs) Dr. Comfort full contact custom diabetic inserts (A5513 compliant).

individual (enter “6” for 3 pairs) Dr. Comfort Elite inserts (A5512 compliant).

I authorize Medicare and my supplemental insurance to pay directly, as I am satisfied with the fit of the shoes and inserts I received. I understand Medicare may reimburse for up to one pair of shoes (2 individual) and 3 pairs of inserts (6 individual) per calendar year. I understand that I am responsible for any deductible and unpaid balance that Medicare or my co-insurance does not cover. I have not received any other shoes or inserts under this plan from any other supplier in this calendar year.

Patients Warranty Statement: We, the Supplier, will accept returns of any Dr. Comfort shoes, for any reason, within thirty days of the shoes being dispensed. If, within thirty days, we determine the shoes do not fit properly, we will replace them at no charge with a properly fitted shoe. Dr. Comfort shoes that have been dispensed for a period of over thirty days will only be exchanged or credited at the Supplier’s discretion. Any shoes that are returned must be returned in the original shoebox.

Supplier Standards and Break in Procedure: The Supplier has provided me with a copy of the Medicare DMEPOS Supplier Standards, as well as Shoe Care Instructions, and has educated me on the proper break-in procedure for my Dr. Comfort shoes.

Patient Signature: Date:

Witness: Date:

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