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 January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 46%.

Top Medical Necessity Denial Reasons

• The medical record documentation does not demonstrate the beneficiary has one or more qualifying conditions.
• The medical record documentation demonstrates the in-person visit was not conducted by the certifying physician.
• The documentation does not demonstrate an in-person evaluation with the beneficiary wearing the shoes and inserts.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• The medical record documentation is not authenticated (handwritten or electronic) by the author.   Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4.
• The medical record documentation contains an error not otherwise specified.

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.