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Therapeutic Shoes/Inserts for Diabetics Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for therapeutic shoes and inserts for diabetic persons HCPCS codes A5500, A5512, and A5513 reviewed between April 1 and June 30, 2024. The error rate for this quarter is 46.26%. The top ten reasons for claim denials are as follows:

Rank Reason Percent
1. Medical record documentation does not include a clinical foot evaluation either conducted by the certifying physician or approved, initialed, and dated by the certifying physician. Therefore, there is no verification that the beneficiary had one of the 6 conditions the LCD specifies must be present for coverage. 18.83%
2. The file does not include medical records from the certifying physician. 12.01%
3. The supplier in-person shoe selection evaluation did not include measurements of the beneficiaries’ feet. 9.74%
4. Medical records do not include a certifying physician clinical evaluation which discusses the management of the beneficiary's systemic diabetes condition within 6 months prior to shoe delivery. 5.52%
5. The only information about how the shoes fit was from a beneficiary attestation. The delivery evaluation must include documentation of an independent, objective assessment conducted by the supplier. 5.52%
6. Documentation did not include a Statement of Certifying Physician. 4.22%
7. The examination documenting the medical management of the patient's diabetes may only be performed by a doctor of osteopathy (D.O.), medical doctor (M.D.), or nurse practitioner (NP) or physician assistant (PA) practicing “incident to” the supervising physician’s authority. NP or PA notes pertaining to the provision of the therapeutic shoes and inserts must be reviewed and verified by the supervising physician. 3.90%
8. The Certifying Physician must be a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or nurse practitioner (NP) or physician assistant (PA) practicing “incident to” the supervising physician’s authority. The Certifying Physician may not be a podiatrist or clinical nurse specialist.  3.57%
9. The medical records do not verify that the certifying physician is managing the patient's diabetes. 2.92%
10. The date of the foot exam was more than six (6) months prior to delivery. 2.92%

*The total percentage will be greater than 100% because some claims denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.

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Updated July 29, 2024

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