Therapeutic Shoes for Persons with Diabetes (TSPD) Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) A5500 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 - September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 59%.

Top Medical Necessity Denial Reasons

  • The documentation does not demonstrate an objective assessment of the fit of the shoe and inserts.
  • The medical record documentation demonstrates the in-person visit was not conducted by the certifying physician.
  • The Statement of Certifying Physician was completed after the date of service.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The medical record documentation does not contain a treating practitioner's signature as required per statute, regulation, national coverage determination (NCD) or local coverage determination (LCD). Refer to 42 Code of Federal Regulations 410.38 (c) & Medicare Program Integrity Manual 100- 08, Chapter 3, Section 3.3.2.4.
  • The certifying physician has not initialed, dated and indicated agreement with the information from the medical record documentation of the in-person visit by another practitioner prior to signing the certification statement.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the TSPD webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.

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