About Medicare Reimbursement for Dr. Comfort Providers

Medicare reimbursement for each diabetic footwear item may change annually, which is why it’s important to stay up-to-date on Medicare reimbursement guidelines. Medicare and supplemental insurance may reimburse for all or part of the cost of Dr. Comfort shoes and prescription inserts for diabetics who meet certain criteria.

Medicare (Part B) Reimbursement Guidelines

Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met:

1. The beneficiary has diabetes mellitus and
2. The certifying physician has documented in the beneficiary's medical record one or more of the following conditions:
   1. Previous amputation of the other foot, or part of either foot, or
   2. History of previous foot ulceration of either foot, or
   3. History of pre-ulcerative calluses of either foot, or
   4. Peripheral neuropathy with evidence of callus formation of either foot, or
   5. Foot deformity of either foot, or
   6. Poor circulation in either foot; and
3. The certifying physician has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes.
4. For claims with dates of service on or after 01/01/2011, the certifying physician must:
   • Have an in-person visit with the beneficiary during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
   • Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.
5. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-person evaluation of the beneficiary.
6. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results. A beneficiary’s subjective statements regarding fit as the sole documentation of the in-person delivery does not meet this criterion.

If criteria 1-5 are not met, the therapeutic shoes, inserts and/or modifications will be denied as non-covered. When codes are billed without a KX modifier, they will be denied as non-covered.

1. Personally, document one or more of criteria a – f in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or
2. Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a – f.

1. One pair of custom molded shoes (A5501) (which includes inserts provided with these shoes) and 2 additional pairs of inserts (A5512 or A5513); or
2. One pair of depth shoes (A5500) and 3 pairs of inserts (A5512 or A5513) (not including the non-customized removable inserts provided with such shoes).

For more information: https://med.noridianmedicare.com/documents/2230703/7218263/Therapeutic+Shoes+for+Persons+with+Diabetes/

To look up current reimbursement rates for specific HCPC codes based on the most recent Medicare Fee Schedule, go to: https://www.dmepdac.com/dmecsapp/do/search.