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Diabetic shoes prescription example

Diabetic footwear prescription form 2021-2025

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The document is a Diabetic Footwear Prescription Form that requires patient information, diagnosis codes (ICD-10), and medical necessity documentation for prescribing diabetic footwear and inserts. It outlines covered procedures, types of footwear and inserts available, Medicare coverage details, and physician information for prescription validation.

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Click ‘Get Form’ to open the diabetic footwear prescription form 2021 in the editor.
Begin by entering the patient's name, ID number, and date of birth in the designated fields at the top of the form.
Indicate the appropriate ICD-10 code for the patient's diagnosis. Ensure that you include all relevant codes as insurance requires them for patient records.
In the 'Covered Procedures' section, check all applicable boxes that pertain to lower limb amputations or foot ulcers.
For inserts, indicate any conditions present by checking the corresponding boxes under 'For Inserts Indicate Below'.
Select the number of pairs needed for depth shoes and custom inserts from the options provided.
Complete any special Rx instructions if necessary and ensure that all physician information is filled out accurately at the bottom of the form.

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Versions	Form popularity	Fillable & printable
2016	4.5 Satisfied (27 Votes)
2014	4.4 Satisfied (39 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How can I get a free pair of diabetic shoes?

Most insurance companies, including Medicare, cover the cost of one pair of diabetic shoes as well as up to 3 pairs of plastazote inserts per calendar year. *Co-payments, deductibles, and some restrictions may apply. Use the button below to download MEDICARE prescription form.

What qualifies you for diabetic shoes?

Candidates for the Diabetic Shoe Program should docHub that you have diabetes, are undergoing treatment and require diabetic shoes as part of the treatment, and have at least one of the following conditions in one or both feet: Partial or complete amputation of the foot. Foot ulceration history. Foot deformity.

What equipment is needed for a diabetic foot exam?

Includes polypropylene case with either a bi-directional (MD2) or non-directional (D900) Dopplex Doppler and 8 Mhz probe, sphygmomanometer, arm/ankle, large and small toe cuff, 10g monofilament, educational video, ABPI and TBPI guide, tube of gel and headphones.

What to document for diabetic shoes?

Physician complete all required paperwork: o Statement of docHubing Physician for Therapeutic Shoes o Prescription/Standard Written Order o Office Visit Notes from prescribing provider and physician that treats your diabetes. These evaluations must be within 6 months prior to receiving your shoes and/or inserts.

Does Medicare pay for a pair of shoes for diabetics?

Medicare will only cover your therapeutic shoes if your doctors and suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers arent enrolled, Medicare wont pay the claims they submit.

What documentation is needed for diabetic shoes?

o Statement of docHubing Physician for Therapeutic Shoes o Prescription/Standard Written Order o Office Visit Notes from prescribing provider and physician that treats your diabetes. These evaluations must be within 6 months prior to receiving your shoes and/or inserts.

What is the code A5500 for diabetic shoes?

An A5500 shoe is an off-the-shelf shoe manufactured to accommodate particular needs for diabetics and that has met all the specifications to qualify for reimbursement through Medicare and other health insurances providers. The A5500 is a standardized code used by these entities for healthcare claims.

What are the Medicare guidelines for diabetic shoes 2025?

Your therapeutic shoes under Medicare arent entirely free. If enrolled in Original Medicare, you must pay a monthly premium starting at $185 in 2025, depending on your income. You also have to meet a $257 annual deductible. Once you do, Part B pays for 80% of the cost of the shoes.

Diabetic footwear prescription form 2021-2025

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