Medicare covers depth or custom-molded shoes and inserts for a patient with diabetes only when the physician managing the diabetes certifies the need. This one-page statement, recommended by the DME MACs, carries the four certification statements, the qualifying foot conditions, and the physician's signature and NPI. The shoe supplier keeps it on file with the order and the medical records that support it.
The certifying physician, an MD or DO who manages the patient's diabetes, completes and signs the whole statement; a podiatrist or clinical nurse specialist cannot certify, and a nurse practitioner or PA only incident to a supervising physician. A separate prescribing practitioner, who may be a podiatrist, writes the order for the shoes and inserts.
Enter the patient's name and Medicare Beneficiary Identifier. The statement is a flat one-page PDF with no fillable fields, so it is printed and completed by hand or typed before signing. Everything below these lines is introduced by 'I certify that all of the following statements are true,' so each of the four statements must apply.
Certify that the patient has diabetes mellitus, the first coverage criterion in the DME MAC policy. Your medical record, not only this statement, should show the diagnosis, and your in-person visit within 6 months before delivery must address diabetes management, because that visit is the basis for everything you certify here.
Circle every condition that applies: history of partial or complete amputation of the foot, history of previous foot ulceration, history of pre-ulcerative callus, peripheral neuropathy with evidence of callus formation, foot deformity, or poor circulation. You must personally document at least one of these in the record of an in-person visit within 6 months before delivery, or initial, date and indicate agreement with another practitioner's note that documents it.
Certify that you are treating the patient under a comprehensive plan of care for diabetes. This is why the certifier must be the MD or DO who manages the diabetes rather than the foot specialist. The policy requires an in-person visit with you during which diabetes management is addressed, within 6 months before the shoes or inserts are delivered.
Certify that the patient needs depth or custom-molded shoes because of diabetes. The specific shoes, modifications and inserts are ordered by the prescribing practitioner. The supplier must examine the feet and take measurements, take impressions, casts or CAD-CAM images for custom items, and objectively assess the fit at delivery while the patient wears the items.
Sign and date the statement on or after the date of your in-person visit and within 3 months before delivery. Print your name; the form states it must be an MD or DO. Add your address and NPI. If you relied on another practitioner's foot examination, initial, date and indicate agreement with that note before signing here.
Download the current version from the source each time; forms change without notice.
Statement of Certifying Physician for Therapeutic Shoes
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Sources for this guide
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No. The certifying physician must be an MD or DO who manages the patient's diabetes, and the DME MAC policy states that a podiatrist cannot be the certifying physician. A podiatrist can, however, be the prescribing practitioner who writes the order and can also be the supplier who fits and dispenses the shoes.
Only incident to a supervising physician. In that case the supervising MD or DO must document management of the diabetes and sign and date the nurse practitioner's or PA's notes. Nurse practitioners and PAs can act as the prescribing practitioner who writes the order for the shoes and inserts.
Timing is tied to delivery. The statement must be signed on or after the date of your in-person visit and within 3 months before the shoes or inserts are delivered. That visit, in which diabetes management is addressed, must fall within 6 months before delivery. A statement signed earlier than 3 months before delivery does not meet the rule.
The DME MACs recommend it and link it from their forms pages, but another form is acceptable if it contains all the elements of the recommended one. Either way the statement does not replace documentation: your in-person visit note must itself record the qualifying foot condition and that diabetes management was addressed.