Here’s a common scenario: The Patient only wants inserts and they already have shoes. Is this allowed?
This is an all-too-common scenario where a patient states they have enough shoes and only want the inserts (e.g. A5514) that are covered under the therapeutic shoe program. You may or may not even be the original supplier or provided them with these shoes. Can you provide them with just inserts?
As physicians and suppliers, we have a dual obligation to ensure that the orthotics or inserts we provide will fit into an appropriate shoe and are medically appropriate. Secondary to that is that Medicare will only cover inserts which are placed into a shoe which meets the requirements of the Therapeutic Shoe Policy. This can be determined by noting whether the shoe is validated on the PDAC website or if the shoe meets the sizing, width, depth, closure and other qualifications of the therapeutic shoe policy. If that is the case then the inserts can be dispensed and covered separately from the shoes. The claim form would simply delineate on separate lines the A5514 codes with the KX modifier and with the left and right foot modifiers along with the appropriate number of inserts for each.
An example of the above is a patient received a pair of shoes in 2024 (or previous years) and has several pairs of shoes which are in good shape. They now only wish to replace their inserts (e.g. A5514) for 2025.
In this scenario, your chart documentation should name the shoes the inserts will be placed into and that they meet the requirements of the therapeutic shoe policy. One should document that the shoe (Brand X) is either listed on the PDAC validation website (DMECS) or that the shoes meet the merits of the Therapeutic Shoe Policy. That is the shoes come in required size, width, closure and depth requirements of the shoe policy.
If you ordered the shoes originally, it is likely you would know if the shoes were validated by the PDAC, as your shoe vendor would identify that to you on their website and ordering forms.
If you did not order the shoes, you would need to either look them up on the PDAC website or take the painstaking path of reviewing the shoe policy and determine if the shoes meet those requirements (not recommended).
All the other paperwork requirements for inserts are the same as if you were dispensing shoes.
To sum up, it is not imperative that shoes and inserts be dispensed at the same time or that the patient receives shoes from you at all. Patients in fact can elect to have inserts dispensed in January of 2024 and then choose to have a pair of shoes dispensed by the same or different supplier in December of 2024. Just remember, that the paperwork for the inserts will not cover the shoes later in the year, nor will the paperwork for the shoes dispensed in December 2024, cover the inserts dispensed in January 2024.
