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 January 2024 - March 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 38%.

Top Medical Necessity Denial Reasons

  • Medical record documentation does not demonstrate the beneficiary has one or more qualifying conditions.
  • The Statement of Certifying Physician was completed prior to the in-person visit.
  • 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.
  • Claim submitted is a duplicate to another claim billed.
  • Medical record documentation contains a practitioner’s signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements.

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 Apr 24 , 2024