Comprehensive Diabetic Foot Exam, WorryFree DME SM Shoe Order Form First perform CDFE, then use WorryFree DME! Perform CDFE on 50% or more of patients with Medicare and diabetes and qualify for PQRS end of year bonus from Medicare ADA recommends patients with diabetes to have annual exam to determine level of risk for ulceration. Enter shoe ordering information at safestep.net for WorryFree DME For Medicare orders, SafeStep will: Obtain from certifying physician signed and dated copy of Certifying Statement Ensure that Certifying Physician has in their chart a copy of relevant medical records indicating agreement with findings qualifying patient for therapeutic shoes. $10,000 Guarantee If SafeStep creates customized documentation forms required of the Supplier and you fail a Medicare audit due to insufficient documentation and exhaust all appeals, SafeStep will reimburse up to $10,000 of loss.* *Guarantee limited to documentation custom generated by SafeStep and required by Medicare. Guarantee only applies to situations where liability is based solely on inadequate documentation. Other issues such as medical necessity, improper code selection and over utilization do not apply. Medicare Compliance Documentation Checklist Complete this form to create: 1. Prescription for Diabetic Shoes and Inserts 2. Documentation of Patient Evaluation Prior to Shoe Selection Enter information at safestep.net. WorryFree DME will create and fax to MD: Don't waste time faxing forms yourself, let SafeStep do it 3. Physician tes on Qualifying Condition(s) 4. Statement of Certifying Physician Once signed forms received from Certifying Physician, WorryFree DME will create: 5. Certificate of Patient Receipt Once shoes indicated as being dispensed, "WorryFree DME will create:: 6. In Person Dispensing Chart tes Enter orders at SafeStep.net Questions? Call 866.712.STEP (7837) Page 1 of 6
Comprehensive Diabetic Foot Exam & WorryFree DME SM Shoe Order Form Complete form for ordering shoes and inserts using WorryFree DME at SafeStep.net Patient Information (Only complete if information not yet in SafeStep system): Title: Mr. Ms. Mrs. Dr. Gender: M F Name: Address: City: Phone: State: ( ) Date of Birth: Zip Code: Email: Patient's insurance ID #: If patient has Medicare, is it the primary insurance? If patient has diabetes and Medicare, has he/she received shoes under the Therapeutic Shoe Program this calendar year? Which feet does patient have? Both Left Right Certifying Physician Managing Diabetes Care (Only complete if information not yet in SafeStep system): Degree: MD DO Name: Address: City: State: Zip Code: Phone: ( ) Fax: ( ) Has signed Statement from Certifying Physician specifying that the Beneficiary has diabetes, risk factor(s) and is under a comprehensive plan of care been received? t Required Has signed copy of Relevant Medical Records Documenting that Beneficiary Has Qualifying Risk Factor(s) been received from Certifying Physician? t Required By selecting you certify that signed, dated copies of required compliance documentation are in the patient's chart. Page 2 of 6
Documentation of Patient Evaluation Prior to Shoe Selection Patient visit may be billable as 99213 if there is documented change in patient's condition. Estimated duration of diabetes: Date of last CDFE: Date last seen by MD/DO*: Date last eye examination: *Medicare requires that for shoes to be covered, the patient must be seen by the physician managing the diabetes no more than six month prior to when shoes fit. Do you examine your feet daily? Last HbA1c: Changes in Allergies: Last FBS (mg/dl): Changes in medications: Current exercise schedule: Foot Complaints: Review of Patient s Symptoms (Check all that apply) Ortho: Joint aches/pains Deformities Stiffness Weakness Have you fallen in the past? Do you stumble or shuffle when you walk? Do you have to touch or hold onto the wall or furniture while walking? Do your legs or ankles feel weak or unsteady? If there is history of falls or unsteadiness, consider fall risk assessment Derm: Skin Rash Pruritus (Itching) Nail Changes Scaling Dryness Neuro: Numbness Tingling Paresthesia Dysthesia Hyperesthesia Vascular: Claudication Edema Temperature Changes Endocrine: Polyuria Polydipsia Polyphagia Co-Morbidities: Retinopathy Nephropathy If there is evidence of neuropathy, consider nerve fiber density testing, NeuRemedy Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest? Do you experience any pain at rest in your lower leg(s) or feet? Do you experience foot or toe pain that often disturbs your sleep? Are your toes or feet pale, discolored, or bluish? Do you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks)? Has your doctor ever told you that you have diminished or absent pedal (foot) pulses? Have you suffered a severe injury to the leg(s) or feet? Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)? If there is evidence of PVD, consider non-invasive vascular testing Physical Exam Vascular (PQRS G8410, 2028F) Right Left Dorsalis Pedis Posterior Tibial Capillary Refill Time Edema Present Other palpable non palpable palpable non palpable palpable non palpable palpable non palpable <3 sec. >3 sec. <3 sec. >3 sec. yes no yes no If there is evidence of PVD, consider non-invasive vascular testing Neurological (PQRS G8404, G8410, 2028F) Right Left Vibration perception (1st MPJ) Loss of Protective Sensation (# of sites) DTR Sharp/Dull diminished normal diminished normal diminished normal diminished normal diminished normal diminished normal If there is evidence of neuropathy, consider nerve fiber density testing, NeuRemedy Page 3 of 6 Dermatological (PQRS G8410, 2028F) Right Left Tina Pedis Xerosis Skin Fissure Ulceration Gangrene Infection Locations (Current, Past) Onychomycosis Interdigital Spaces Keratomas (Calluses) Temperature Assessment Areas of Increased Focal Temperature (number) Other clear macerated clear macerated inc. dec. norm. inc. dec. norm.
Documentation of Patient Evaluation Prior to Shoe Selection (Continued) Patient visit may be billable as 99213 if there is documented change in patient's condition. Physical Exam (Continued) Orthopedic (PQRS G8410, 2028F) Right Left Right Left Foot Deformities (including hallux valgus, hammertoes) Equinus Plantarflexed Metatarsal Charcot Deformities Previous Amputations Other Quantified areas of excessive pressure Foot Type Class findings: te corns, calluses or deformities using symbol key below: Corn/Callus (C) Wound (W) Bunion (B) Redness (R) Swelling (S) Hammer/Claw toe (HC) Amputation (A) If patient has previously received shoes covered by Medicare, are they worn and in need of replacement? If patient has previously received inserts covered by Medicare, are they worn and in need of replacement? Shoe Size based on measuring device, fit of currently worn shoes and try-on sample: Length: Width: Education and Counseling General Medications Explanation of systemic risks of diabetes and importance of proper glucose control. Explanation of dangers of neuropathy and loss of gift of pain Counseling on risk stratification and exam frequency Review of current medications Risk Stratification (recommended exam frequency) (0) Neuropathy Annual (1) Neuropathy Semi-Annual (2) Neuropathy, PVD and/or deformity - Quarterly (3) Previous Ulcer or amputation monthly to every 2 months Actions Taken Prescriptions ordered: Referred to (Physician's Name or Department): Reason for Referral: Diagnostic Studies: Fall Risk Assessment n-invasive vascular testing Nerve fiber density testing Other: Procedures: Duration of visit: min. Physician Supervising CDFE: (Should be the same as the physician prescribing and supervising fitting of footwear.) Perform PQRS measures and submit codes to earn end of year bonus. For more information, go to SafeStep.net. Page 4 of 6
Information for Statement of Certifying Physician and Physician tes on Qualifying Condition(s) Once entered into WorryFree DME, SafeStep will use the information below to obtain signed, dated copy of the Statement of Certifying Physician and for physician notes on qualifiying condition(s). Statement of Certifying Physician valid for three months after date of signature. Diabetes Type: Type II, Controlled Type I, Controlled Type II, Uncontrolled Type I, Uncontrolled Primary diagnosis: Diabetes with neurological manifestations Diabetes with peripheral circulatory disorder Diabetes without neurovascular manifestations and with structural deformity Foot Deformity Arthropathy associated with neurological disorders (713.5) Bunion (727.1) Claw toe (735.5) Hallux rigidus (735.2) Hallux valgus (735.0) Hammer toe (735.4) Unspecified deformity of ankle and foot, acquired (736.70) Unspecified acquired deformity of toe (735.9) History of partial or complete amputation of the foot Lower limb amputation, foot (V49.73) Lower limb amputation, great toe (V49.71) Lower limb amputation, lesser toe(s) (V49.72) History of preulcerative callus Corn / Callus (700) sub metatarsal right left sub hallux right left 1st toe right left 2nd toe right left 3rd toe right left 4th toe right left 5th toe right left History of previous foot ulceration Ulcer of heel and midfoot (707.14) heel right left styloid right left Ulcer other part of foot (707.15) sub metatarsal right left sub hallux right left 1st toe right left 2nd toe right left 3rd toe right left 4th toe right left 5th toe right left Peripheral neuropathy with evidence of callus formation Neuropathy in diabetes, use w/ 250.60, 250.61 (357.2) loss of vibratory sensation loss of protective sensation loss of deep tendon reflexes loss of sharp / dull Poor circulation Atherosclerosis of the extremities with intermittent claudication (440.21) Atherosclerosis of the extremities with ulceration (440.23) Atherosclerosis of the extremities, unspecified (440.20) Peripheral angiopathy (443.81) Peripheral vascular disease unspecified (443.9) diminished dorsalis pedis pulse right left bilateral diminished posterior tibial pulse right left bilateral increased capillary refill time right left bilateral Helpful information and forms: Comprehensive Diabetic Foot Exam and "WorryFree DME Shoe Order Forms AFO information kit Fall prevention information kit Fall prevention patient brochures MBB order forms Shoe catalogs Order online at SafeStep.net or call 866.712.STEP (7837) The codes contained herein are not the official position or endorsement of any organization or company. They are offered as a suggestion based upon input from previous customers. Each prescribing practitioner should contact his or her local carrier or Medicare office to verify billing codes, regulations and guidelines relevant to their geographic location. Page 5 of 6
Prescription for Diabetic Shoes and Inserts Use this information when entering order online for shoes & inserts using "WorryFree DME Patient Name: Date: Shoes: Shoe Brand/Description: Shoe Item #: Gender: Size: Width: Inserts: Prefabricated, Heat Molded Inserts (A5512) - Pairs, Quantity: 3 2 1 Custom Molded Inserts (A5513) - Pairs, Quantity: 3 2 1 Insert Type: (Better) Bilaminar (Best) Trilaminar with blue cushioned layer Partial Foot Fillers (L5000): (Must include foot tracing for partial foot filler) 1 left partial foot filler (L5000) 1 right partial foot filler (L5000) 3 left custom inserts 3 right custom inserts Primary Diagnosis Code:. Please confirm that the entered Diagnosis Codes match your charting documentation. Diabetes, without complications 250.00 Type II controlled 250.01 Type I controlled 250.02 Type II uncontrolled 250.03 Type I uncontrolled Duration of usage: 12 months Diabetes with neurological manifestations 250.60 Type II controlled 250.61 Type I controlled 250.62 Type II uncontrolled 250.63 Type I uncontrolled Diabetes with peripheral circulatory disorders 250.70 Type II controlled 250.71 Type I controlled 250.72 Type II uncontrolled 250.73 Type I uncontrolled Signature of Prescribing Physician: Print Name of Prescribing Physician: Date: (should be same as physician supervising fitting of footwear) Enter orders at SafeStep.net Questions? Call 866.712.STEP (7837) Page 6 of 6