Documentation Requirements
Certification Statement
The supplier must obtain a signed statement from the
certifying physician specifying:

1.That the patient has diabetes mellitus.
2. Has one of the conditions 2a-2f listed in the policy who qualifies
3. Is being treated under a comprehensive plan of care for his/her diabetes
4. Needs diabetic shoes.

The Statement of Certifying Physician for Therapeutic Shoes developed by
the DMERC is recommended (The DMERC form is included in the SureFit
Forms Package). The certifying physician must be either an M.D. or D.O.
and may not be a podiatrist. This statement may be completed by the
prescribing physician or supplier (podiatrist) but must be reviewed for
accuracy and signed by the certifying physician (M.D. or D.O.) to indicate
agreement. A new Certification Statement is required for a shoe, insert or
modification provided more than one year from the most recent Certification
Statement date on file. A copy of the Certification Statement should remain in
the supplier’s patient chart. To indicate that a current signed statement
is on file a KX modifier must be added to the claim form.

Prescription
The supplier of shoes, inserts or modifications must keep on file an order
signed and dated by the prescribing physician. If the prescribing physician
is the supplier (such as a podiatrist), a separate order is not required,
however, the item provided must be clearly noted in the patient's record.
A new order is not required for the replacement of an insert or modification
within one year of the current order. However, the supplier's records
should document the reason for the replacement. A new order is required
for the replacement of any shoe. A new order is also required for the
replacement of an insert or modification more than one year from the
most recent order on file.

Office Records
As with any service reimbursed by Medicare, the agency, at its discretion,
may elect to perform an audit of the supplier’s documentation to support
the payments received. The documentation must demonstrate both medical
necessity and the level of service provided. In the case of diabetic footwear,
the documentation of medical necessity is straightforward. The therapeutic
footwear bill assigns that responsibility to the certifying physician (M.D., D.O.)
providing the medical care for the patient’s diabetic condition.
The Statement of Certifying Physician form is retained in the supplier’s chart
and provides the documentation necessary to demonstrate medical necessity.

Medicare instituted a new coding structure for diabetic inserts as of April 1,
2004. The new codes will assist Medicare in identifying the specific
fabrication technique used to provide the service. Medicare considers a
prefabricated insert as a precursor to the finished device. Coverage is
determined by the fabrication method and the achievement of total contact.
The service documentation required would depend on the level of service
provided (A5512 - A5513).

A5513 – A custom fabricated insert made from a model of the patient’s foot.
Documentation: The orthotic laboratory invoice for a custom molded total
contact device.

A5510 – Prefabricated insert compression molded to the foot without heat
source. Documentation: None required, this fabrication technique is a non
covered service and will deny payment.

A5512 – Prefabricated insert molded directly to the foot with external heat
source. Documentation: Vendor’s invoice for an insert capable of achieving
total contact via external heating and direct molding to the foot. Medical
notes documenting the direct molding technique utilized to achieve and
verify total contact with the plantar surface of the foot. The physician is
responsible for documenting the achievement of total contact to
qualify for coverage.

A5500 – Off-the-shelf depth-inlay shoe manufactured to accommodate
multi-density insert. Documentation: Vendor’s invoice for a depth shoe
that meets Medicare guidelines.