Therapeutic Shoes for Persons with Diabetes Quarterly Results of Targeted Probe and Educate Review - JD DME
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. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 8%.
Top Medical Necessity Denial Reasons
- Documentation does not demonstrate measurements of the beneficiary’s feet were obtained.
- Documentation does not demonstrate an objective assessment of the fit of the shoe and inserts.
- Documentation does not demonstrate an in-person evaluation with the beneficiary wearing the shoes and inserts.
Top Technical Denial Reasons
- 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.
- Related item denied: Order
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.
