Therapeutic Shoes 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 A5500. The quarterly edit effectiveness results from October 2023 - December 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 55%.

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.
  • Statement of Certifying Physician does not specify the beneficiary has one or more qualifying conditions.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Claim submitted is a duplicate to another claim billed.
  • Medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section

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.

Last Updated Jan 29 , 2024