For physicians, podiatrists, and DME suppliers
By Tatiana Kantor, Billing Department, WCH; President of AAPC Tashkent Chapter
Medicare’s 2024 data shows an improper payment rate of 47.1% for diabetic therapeutic shoe claims — a projected $35.7 million in incorrect payments. The leading cause is insufficient documentation, which accounts for 85.5% of all errors. Providers must take immediate steps to ensure full compliance.
| Improper payment rate 47.1% | Due to missing docs 85.5% | Projected overpayment $35.7M |
Who Is Affected?
This notice applies to physicians (MDs and DOs) managing diabetic patients’ systemic conditions, podiatrists, other qualified physicians involved in fitting diabetic shoes, and DME suppliers billing these services under Medicare Part B.
Patient Eligibility Criteria
Coverage applies when the patient has a confirmed diagnosis of diabetes mellitus and the medical record documents at least one of the following conditions:
- Peripheral neuropathy with evidence of callus formation
- History of pre-ulcerative calluses on either foot
- History of previous foot ulceration
- Foot deformity
- Previous amputation of foot or part of foot
- Poor circulation in either foot
Key Documentation Checklist
1
Physician’s medical record documents the diabetes diagnosis and at least one qualifying foot condition.
2
Certifying physician had an in-person visit with the patient within 6 months before delivery of the shoes.
3
Signed certification statement completed within 3 months before delivery, confirming diabetes management under a comprehensive plan of care.
4
Supplier completed and documented an in-person evaluation prior to selecting items, plus an objective fit assessment at delivery. A patient’s verbal statement alone is not sufficient.
5
Claims billed with a KX modifier to confirm documentation is on file. Claims without this modifier are automatically denied as non-covered.
Common Denial Scenario
A claim submitted with a standard written order, proof of delivery, and a partial medical record — but without a complete physician certification in the record — will be flagged as insufficient documentation. The MAC will recoup the payment.
Coverage Limits (per calendar year)
Medicare covers either one pair of custom-molded shoes with up to 2 additional pairs of inserts, or one pair of depth shoes with up to 3 pairs of inserts. Note that the benefit covers a full pair of shoes even if only one foot is affected.
For complete policy details, refer to LCD L33369 and Article A52501. Questions about billing and coverage should be directed to your DME Medicare Administrative Contractor (MAC).
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