Information for Statement of Certifying Physician and Physician Notes 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
History of previous foot ulceration
Ulcer of heel and midfoot (707.14)
heel
right
styloid
right
left
left
Ulcer other part of foot (707.15)
right
sub metatarsal
sub hallux
right
1st toe
right
2nd toe
right
3rd toe
right
4th toe
right
5th toe
right
left
left
left
left
left
left
left
Foot Deformity
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
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)
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
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
sub hallux
1st toe
2nd toe
3rd toe
4th toe
5th toe
right
right
right
right
right
right
right
left
left
left
left
left
left
left
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. The
offered as a suggestion based upon input from previous customers. Each prescribing practitioner should cont
or her local carrier or Medicare office to verify billing codes, regulations and guidelines relevant to the
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:
3
Prefabricated, Heat Molded Inserts (A5512) - Pairs, Quantity:
Custom Molded Inserts (A5513) - Pairs, Quantity:
Insert Type:
(Better) Bilaminar
3
2
2
1
1
(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
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
Duration of usage: 12 months
Signature of Prescribing Physician:
Date:
Print Name of Prescribing Physician:
(should be same as physician supervising fitting of footwear)
Enter orders at SafeStep.net
Questions? Call 866.712.STEP (7837)
Page 6 of 6
Comprehensive Diabetic Foot Exam,
“WorryFree DME” Shoe Order Form
SM
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 Notes 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 Notes
Enter orders at SafeStep.net
Questions? Call 866.712.STEP (7837)
Page 1 of 6
Comprehensive Diabetic Foot Exam & “WorryFree DME” Shoe Order Form
SM
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
Gender:
Dr.
M
F
Name:
Address:
City:
State:
(
Phone:
Zip Code:
)
Date of Birth:
Patient's insurance ID #:
Email:
If patient has Medicare, is it the primary insurance?
Yes
No
If patient has diabetes and Medicare, has he/she received shoes
under the Therapeutic Shoe Program this calendar year?
Which feet does patient have?
Bot
Left
Yes
No
Right
Certifying Physician Managing Diabetes Care (Only complete if information not yet in SafeStep system):
Degree:
MD
DO
Name:
Address:
City:
Phone:
State:
(
)
Zip Code:
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?
Yes
No
Not Required
Has signed copy of “Relevant Medical Records Documenting that Beneficiary Has Qualifying Risk Factor(s)” been received from Certifying Physician?
Yes
No
Not Required
By selecting “Yes” 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 FBS (mg/dl):
Last HbA1c:
Changes in medications:
Changes in Allergies:
Current exercise schedule:
Foot Complaints:
Review of Patient’s Symptoms (Check all that apply)
Ortho:
Vascular:
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:
Neuro:
Skin Rash
Pruritus (Itching)
Nail Changes
Scaling
Dryness
Numbness
Tingling
Paresthesia
Dysthesia
Hyperesthesia
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?
Yes
No
Do you experience any pain at rest in your lower
leg(s) or feet?
Yes
No
Do you experience foot or toe pain that often
disturbs your sleep?
Yes
No
Are your toes or feet pale, discolored, or bluish?
Yes
No
Do you have skin wounds or ulcers on your feet or
toes that are slow to heal (8-12 weeks)?
Yes
No
Has your doctor ever told you that you have
diminished or absent pedal (foot) pulses?
Yes
No
Have you suffered a severe injury to the leg(s) or feet?
Yes
No
Do you have an infection of the leg(s) or feet that
may be gangrenous (black skin tissue)?
Yes
No
If there is evidence of PVD, consider
non-invasive vascular testing
Physical Exam
Vascular
Right
(PQRS G8410, 2028F)
Dermatological
Left
Dorsalis Pedis
palpable
non palpable
palpable
non palpable
Tina Pedis
Posterior Tibial
palpable
non palpable
palpable
non palpable
Xerosis
Capillary Refill Time
<3 sec.
>3 sec.
<3 sec.
>3 sec.
Skin Fissure
Edema Present
yes
no
yes
no
Ulceration
Other
Gangrene
If there is evidence of PVD, consider non-invasive vascular testing
Infection Locations
(Current, Past)
Neurological
(PQRS G8404, G8410, 2028F)
Vibration perception
(1st MPJ)
Right
normal
diminished
normal
Loss of Protective
Sensation (# of sites)
clear
macerated
clear
macerated
Keratomas (Calluses)
Temperature Assessment
DTR
diminished
normal
diminished
normal
Areas of Increased Focal
Temperature (number)
Sharp/Dull
diminished
normal
diminished
normal
Other
If there is evidence of neuropathy, consider nerve fiber
density testing, NeuRemedy
Left
Onychomycosis
Left
Interdigital Spaces
diminished
Right
(PQRS G8410, 2028F)
Page 3 of 6
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)
Right
Orthopedic (PQRS G8410, 2028F)
Right
Left
Left
Foot Deformities
(including hallux valgus, hammertoes)
Equinus
Plantarflexed Metatarsal
Charcot Deformities
Note corns, calluses or deformities using symbol key below:
Previous Amputations
Corn/Callus (C) Wound (W) Bunion (B) Redness (R)
Swelling (S) Hammer/Claw toe (HC) Amputation (A)
Other
Quantified areas of excessive pressure
Foot Type
If patient has previously received shoes covered by Medicare, are they worn
and in need of replacement?
Yes
No
If patient has previously received inserts covered by Medicare, are they worn
and in need of replacement?
Yes
No
Class findings:
Shoe Size based on measuring device, fit of currently worn
shoes and try-on sample:
Length:
Width:
Education and Counseling
General
Yes
• 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
Medications
• Review of current medications
Risk Stratification (recommended exam frequency)
(0) No Neuropathy – Annual
(1) Neuropathy –Semi-Annual
(3) Previous Ulcer or amputation – monthly to every 2 months
(2) Neuropathy, PVD and/or deformity - Quarterly
Actions Taken
Prescriptions ordered:
Referred to (Physician's Name or Department):
Reason for Referral:
Diagnostic Studies:
Fall Risk Assessment
Non-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
No