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diabetic shoes

My patient has a secondary insurance which will pay for a second pair of shoes in a given year. How do I do this?

2 comments

Comments (2)

Oct 29

If you mean Medicare is primary, then bill Medicare DMERC A5500GYRT and A5500GYLT. This billing will be denied as not covered because the patient already received their Medicare benefit. Another option is A5500GART and A5500GALT, this tells the Medicare DMERC that an ABN was provided. Because they already received their annual benefit, this notifies the Medicare DMERC carrier you notified the patient in advance of non coverage as the therapeutic policy only allows one pair per calendar year. Once you receive the EOB from Medicare, it should have a PR code meaning patient responsibility, then bill the secondary insurance for payment for the second pair.

paulkesselmandpm

Oct 31

Replying to

I would like to add that obtaining an ABN while not technically required, is neverthess a good idea. Medicare considers this second pair, not medically necessary and it statuatorily excluded from coverage. That being said, the templated verbiage from Medicare to you and to the patient, may include referencing to an ABN. Also many auditors will see that and ask for the ABN, though the patient did not pay you and you are simply submitting this to obtain payment from the secondary carrier. The patient may also be upset, thus obtaining an ABN, which simply states that Medicare only covers one pair of shoes annually, which was received on...... Therefore a second pair of shoes in this calendar year (2025) are not covered.

The patient should choose to submit the claim to Medicare.

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