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 October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 32%.
Top Medical Necessity Denial Reasons
- 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 does not demonstrate the beneficiary has one or more qualifying conditions.
- Documentation does not demonstrate an objective assessment of the fit of the shoe and inserts.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
- Standard written order (SWO) is missing the quantity to be dispensed. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 & Standard Documentation Requirements A55426.
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.
