Custom Inserts Shoes Order Form

ICD-10 Diagnosis Code:

E10.9 - Type I Diabetes without complicationsZ89.4 - Absence of ToeE10.8 - Type I Diabetes with complicationsE11.9 - Type II Diabetes without complicationsE11.8 - Type II Diabetes with complicationsM21.40 or M21.41 - Fallen Arch / Pes PlanusM20.4 – ArthropathiesM77.4 – MetatarsalgiaM72.2 – Plantar FasciitisOther

The Patient must have a Documented Hx of one or more of the following to meet Medical Necessity History of previous foot ulceration

History of pre-ulcerative callusPeripheral neuropathy with evidence of callus formationHistory of partial or complete amputation of the footFoot DeformityPoor Circulation

Physician’s Order:

A5500 – For diabetics only...A5512 – Pre-fabricated inserts...A5514 – Custom molded inserts...L3050 – Custom Arch orthotics...L3060 – Custom Arch orthotics Longitudinal

Clinical Evaluation:

CallusUlcersHeelspurBunionBunionetteCharcotHammer toesOverlapped toesMetatarsalgiaPlantar fasciitisToe pain

I am currently treating this patient under a comprehensive plan of care for diabetes mellitus. This patient needs extra depth shoes with multiple density inserts because of his/hers diabetes. I certify that all of the conditions checked above are in my doctor’s notes.

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ICD-10 Diagnosis Code:

The Patient must have a Documented Hx of one or more of the following to meet Medical Necessity History of previous foot ulceration

Physician’s Order:

Clinical Evaluation:

I am currently treating this patient under a comprehensive plan of care for diabetes mellitus. This patient needs extra depth shoes with multiple density inserts because of his/hers diabetes. I certify that all of the conditions checked above are in my doctor’s notes.

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