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 A5500. The quarterly edit effectiveness results from July 2022 - September 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 49%.

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 examination of the beneficiary’s feet with a description of the abnormalities that will need to be accommodated by the shoes/inserts/modifications.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
  • 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.

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.

 

Last Updated Wed, 02 Nov 2022 19:36:51 +0000