Diabetic Shoe Documentation Guidelines Prescription A written prescription order is required from the ordering physician up front for diabetictherapeutic shoes. The written order form may be used for this purpose or a written prescription
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Presentation Transcript
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Diabetic Shoe Documentation Guidelines<br>
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Prescription A written prescription order is required from the ordering physician up front for diabetic/therapeutic shoes. The written order form may be used for this purpose or a written prescription containing this required information.<br>
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Certifying Statement A “statement of certification for therapeutic shoe and inserts” is also required to be signed and dated within 3 months prior to delivery of shoes
The certifying physician must be an MD or DO and may NOT be a Podiatrist, PA, Nurse Practitioner or clinical nurse specialist.<br>
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Keene Medical Order Form for Diabetic Shoes can be found at: https://www.keenemedicalproducts.net/orderforms This form contains the Prescription and Certifying Statement all in one
The MD/DO can complete and sign both areas OR
The MD/DO can complete and sign the top Certifying Statement with the Ordering physician (podiatrist) completing and signing the bottom prescription portion<br>
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MEDICAL GUIDELINES A. The patient must have Diabetes Mellitus.
B. The patient has to have one or more of the following conditions:
1. History of partial or complete amputation of foot
2. History of previous foot ulceration
3. Peripheral neuropathy with evidence of callous formation
4. History of pre-ulcerative callous
5. Foot deformity
6. Poor circulation
C. Patient must have a documented Comprehensive Plan of Care for Diabetes management<br>
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There must be qualifying medical documentation in the medical record The certifying physician (MD/DO) must document the comprehensive plan of care for diabetes management
The certifying physician (MD/DO) must document one or more of criteria 1 – 6 listed on the previous slide in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement;
OR Obtain, initial, date and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria 1-6 listed on the previous slide.<br>
