Therapeutic Shoes for Persons with Diabetes Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction D, 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 July 2025 – September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 22%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not demonstrate the beneficiary has one or more qualifying conditions.
  • The Statement of Certifying Physician was completed after the date of service.
  • The 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.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.

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.

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