Therapeutic Shoes for Persons with Diabetes Quarterly Results of Targeted Probe and Educate Review - JA DME
Therapeutic Shoes for Persons with Diabetes 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. The quarterly edit effectiveness results from January 2025 – March 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 29%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not demonstrate the beneficiary has one or more qualifying conditions.
- Certifying physician has not initialed, dated and indicated agreement with information from the medical record documentation of the in-person visit by another practitioner prior to signing the certification statement.
- Medical record documentation demonstrates the in-person visit was not conducted by the certifying physician.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- No medical record documentation was received.
- Medical record documentation contains an illegible signature and no signature log or attestation statement was submitted. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Therapeutic Shoes 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.
