Let's say a podiatrist's patient is diabetic, the podiatrist is enrolled as a Medicare supplier, but the patient does not appear to meet the medical necessity requirements needed for diabetic shoe reimbursement. Is this podiatrist then able to order shoes from a vendor and sell them to the patient on a cash basis?

 
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  • Quote:

    Let's say a podiatrist's patient is diabetic, the podiatrist is enrolled as a Medicare supplier, but the patient does not appear to meet the medical necessity requirements needed for diabetic shoe reimbursement. Is this podiatrist then able to order shoes from a vendor and sell them to the patient on a cash basis?

     


    The issue is not whether the podiatrist may sell the item as cash.  The problem is that in the Medicare Beneficiary Manual, diabetic patients are covered - no matter if they have no symptomology.  We all know that medically, diabetics (even those without symptoms) have increased foot pressures relative to non-diabetics.  We also know that diabetics have higher levels of MMP in their wounds than non-diabetics. 

    Given the chronic nature of the disease, all diabetics regardless of symptomology qualify for diabetic shoes and therapeutic inserts, based on history alone.  Even an adductovarus 5th toe is considered a digital toe deformity, and thus, qualifies under the shoe program.

    It would be illegal in the CMS system to sell any Medicare beneficiary any item that has an approved A, E, J, or L-approved DMERC, PDAC or Q-code as a cash item.  These patients must fill out an ABN form with the proposed cost of the item and billed to the appropriate DMERC carrier with the "GA" modifier appended to the claim.

    Eric

  • Quote:

    Let's say a podiatrist's patient is diabetic, the podiatrist is enrolled as a Medicare supplier, but the patient does not appear to meet the medical necessity requirements needed for diabetic shoe reimbursement. Is this podiatrist then able to order shoes from a vendor and sell them to the patient on a cash basis?

     


    The issue is not whether the podiatrist may sell the item as cash.  The problem is that in the Medicare Beneficiary Manual, diabetic patients are covered - no matter if they have no symptomology.  We all know that medically, diabetics (even those without symptoms) have increased foot pressures relative to non-diabetics.  We also know that diabetics have higher levels of MMP in their wounds than non-diabetics. 

    Given the chronic nature of the disease, all diabetics regardless of symptomology qualify for diabetic shoes and therapeutic inserts, based on history alone.  Even an adductovarus 5th toe is considered a digital toe deformity, and thus, qualifies under the shoe program.

    It would be illegal in the CMS system to sell any Medicare beneficiary any item that has an approved A, E, J, or L-approved DMERC, PDAC or Q-code as a cash item.  These patients must fill out an ABN form with the proposed cost of the item and billed to the appropriate DMERC carrier with the "GA" modifier appended to the claim.

    Eric