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

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 October 2025 - December 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 70%.

Top Medical Necessity Denial Reasons

• The documentation does not contain a statement of certifying physician for therapeutic shoes.
• The medical record documentation demonstrates the in-person visit was not conducted by the certifying physician.
• The documentation does not demonstrate measurements of the beneficiary’s feet were obtained.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• The documentation does not include a Standard Written Order (SWO).
• The medical record documentation is dated after the date of service.

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.