Therapeutic Shoes & Inserts Note (Diabetes)

Patient Name: [Patient full name] DOB: [Date of birth] Payer ID: [Payer/Insurance ID] Address/Phone: [Mailing address and contact number]

Encounter Date/Time: [Date and time of encounter] Location: [Clinic/site name]

Visit Type: [Evaluation Only / Delivery Only / Combined Evaluation & Delivery]

Evaluation Time: [Timestamp] Delivery Time: [Timestamp] (Include only for Combined visits)

Author: [Name], [Credentials], [Role: pedorthist / orthotist / podiatrist / qualified supplier staff], [Organization]

Certification and Order Information

Certifying Clinician (Diabetes Manager): [Name, credentials, NPI]

Prescribing Practitioner: [Name, credentials, NPI] (May be same as Certifying Clinician)

Supplier/Billing Entity: [Name, NPI/PTAN]

Date of Diabetes Management Visit: [Date] (Must be within payer-required timeframe before delivery)

Certification Statement Date: [Date]

Order Date: [Date]; [signed / pending]

Timing Requirements Met: [Yes / No] (If No, document corrective action or reason delivery is deferred)

(If certification or order elements are pending, explicitly list missing items and note that billing cannot occur until documentation is complete)

Annual Benefit Utilization

Benefit Year: [Calendar year or date range]

Prior Therapeutic Footwear This Benefit Year:

• [Item type] — [Quantity] — [Date(s)] — [Source: medical record / supplier records / patient report] — [Verified / Verification pending]

Items Provided Today:

• [Item type] — [Quantity] — [Left / Right / Bilateral]

Estimated Remaining Eligibility: [Quantity remaining / Unknown—verification pending]

Evaluation

(Include this section for Evaluation Only or Combined visits; omit entirely for Delivery Only visits)

Diabetes Diagnosis and Qualifying Condition

Diabetes Diagnosis: [Diagnosis with ICD-10 code if available]

Qualifying Condition(s) Present: (Do not infer from suggestive findings; must be explicitly documented in medical record)

• [Qualifying condition] — [Left / Right / Bilateral] — Source: [Clinician name], [Record date]

(If qualifying condition documentation is unavailable, state: "Coverage criteria not yet met; awaiting documentation.")

Relevant Foot History

• Prior ulcer history: [Site, date if known, or none]
• Prior amputation: [Level, date if known, or none]
• Prior Charcot or reconstructive surgery: [Details or none]
• Current symptoms: [Numbness, burning, pain, swelling] (Patient-reported)
• Prior therapeutic footwear: [Experience and tolerance] (Patient-reported)
• Ambulation status: [Status and assistive device use]

Foot Examination Findings

(Document only what was assessed)

Right Foot:

• Skin: [Calluses with location, pre-ulcerative lesions, ulcers, fissures, redness, temperature concerns]
• Structural: [Bunion/hallux valgus, hammertoes, Charcot changes, prominent metatarsal heads, arch abnormalities, limb length discrepancy]
• Edema/Volume Risk: [Presence, degree, and fluctuation risk]
• Neurologic: [Protective sensation status] (If assessed)
• Vascular: [Pulses, capillary refill] (If assessed)

Left Foot:

• Skin: [Calluses with location, pre-ulcerative lesions, ulcers, fissures, redness, temperature concerns]
• Structural: [Bunion/hallux valgus, hammertoes, Charcot changes, prominent metatarsal heads, arch abnormalities, limb length discrepancy]
• Edema/Volume Risk: [Presence, degree, and fluctuation risk]
• Neurologic: [Protective sensation status] (If assessed)
• Vascular: [Pulses, capillary refill] (If assessed)

Abnormalities Requiring Accommodation: [Summarized list linking abnormalities to accommodation needs, or state "No accommodation-relevant abnormalities identified"]

Measurements

Shoe Size/Width: Right: [Size/Width] | Left: [Size/Width]

Significant Asymmetry: [Yes with details / No]

Additional Measurements: [Arch length, instep girth, forefoot girth, toe box needs as relevant]

Custom Capture Method

(Include only when custom-molded shoes or custom inserts are selected)

Capture Method: [Foam impression / Plaster cast / CAD-CAM scan]

Date/Time: [Date and time of capture]

Performed By: [Name, role]

Quality Check: [Adequate for fabrication / Issues noted—plan to repeat or adjust]

(If deferred, document reason and plan)

Device Selection and Justification

Shoes: [Depth shoes / Custom-molded shoes]; [Brand/Model if known]; Size/Width: R [size/width], L [size/width]; [Closure type]

Shoe Justification: [Link shoe type and features to specific abnormalities requiring accommodation]

Inserts: [Prefabricated total contact / Custom]; [Material/density]; Quantity: [Number]

Insert Justification: [Link to plantar pressure risk areas, prominences, or callus sites]

Modifications: [Type per foot and rationale] (Include only if modifications selected)

Billing Notes: [HCPCS codes and diagnosis codes] (Optional; suppress from patient-facing output)

Delivery

(Include this section for Delivery Only or Combined visits; omit entirely for Evaluation Only visits)

Reference to Prior Evaluation: [Date] by [Clinician name] (Include for Delivery Only visits)

Items Delivered

Delivery Date/Time: [Date and time]

• [Shoes]: [Brand/Model] — R: [Size/Width], L: [Size/Width] — [Closure type] — Qty: [Number] — [Serial/Lot number if applicable]
• [Inserts]: [Type/Material] — [Left / Right / Bilateral] — Qty: [Number] — [Lot/Batch if applicable]
• [Modifications]: [Type] — [Left / Right] — [Details] (If applicable)

Objective Fit Assessment

(Document observable findings; patient subjective comfort alone is insufficient for coverage)

Right Foot:

• Length and toe clearance: [Adequate / Inadequate with details]
• Forefoot width at prominences: [No compression / Compression noted with location]
• Instep volume and closure: [Appropriate / Tight / Loose]
• Heel fit and rearfoot stability: [Secure / Slippage noted]
• Insert seating: [Flat and fully seated / Curling or migration noted]
• Seam/edge irritation: [None observed / Areas of concern]
• Standing and ambulation: [Gait stability, rub points, posture observations]
• Skin check post-trial wear: [Redness/blistering absent / Present at locations] (If feasible)

Left Foot:

• Length and toe clearance: [Adequate / Inadequate with details]
• Forefoot width at prominences: [No compression / Compression noted with location]
• Instep volume and closure: [Appropriate / Tight / Loose]
• Heel fit and rearfoot stability: [Secure / Slippage noted]
• Insert seating: [Flat and fully seated / Curling or migration noted]
• Seam/edge irritation: [None observed / Areas of concern]
• Standing and ambulation: [Gait stability, rub points, posture observations]
• Skin check post-trial wear: [Redness/blistering absent / Present at locations] (If feasible)

Patient Report: [Subjective comfort statement and any concerns voiced]

Adjustments Made

(Include only if adjustments were performed)

• [Adjustment type: heat-molding / spot stretching / closure modification / insert trimming / pads or reliefs added] — [Details] — Outcome after re-check: [Findings]

Proof-of-Delivery: Completed in [System name] on [Date] (If maintained separately)

Patient Education

Education provided on the following topics:

• Gradual break-in schedule
• Daily foot inspection: redness, blisters, callus changes, drainage
• Appropriate socks: clean, moisture-wicking, non-irritating seams
• Never walk barefoot
• When to stop wearing and contact clinician: persistent redness, blistering, new wound, pain in insensate foot, signs of infection
• Insert and shoe care; replacement expectations

[Patient / Caregiver] verbalized understanding. (If patient cannot demonstrate understanding, document caregiver education provided or need for follow-up)

Follow-Up Plan

Routine Follow-Up: [Timeframe for reassessment]

Triggers for Earlier Contact: [Skin changes, persistent redness, new pain or wound, balance issues]

Care Coordination: [Records requested, notifications sent to prescriber/certifier, referrals recommended] (If applicable)

Signature

Author Signature: [Signature] — [Date/Time] — [Credentials] — [Role]

Co-Signature: [Supervising clinician signature] (Include if trainee or assistant contributed)