The Jurisdiction D, DME MAC, Medical Review Department is conducting Targeted Probe and Educate (TPE) reviews of HCPCS code A5500 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2026 – September 2026 are as follows:

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

Top Denial Reasons

• The medical record documentation does not demonstrate the beneficiary has one or more qualifying conditions.
• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• The medical record documentation does not demonstrate an in-person visit with the beneficiary addressing diabetes management.

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.