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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 January 1 and March 31, 2024. The error rate for this quarter is 37.28%. The top 10 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 six conditions the Local Coverage Determination specifies must be present for coverage. 12.58%
2. The Statement of Certifying Physician is dated prior to a documented visit with the certifying physician. 8.06%
3. The file does not include medical records from the certifying physician. 8.06%
4. The written order was signed prior to a documented visit with the prescribing practitioner. 6.13%
5. Medical records do not include a certifying physician clinical evaluation which discusses the management of the beneficiary's systemic diabetes condition within six months prior to shoe delivery. 5.81%
6. 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 about the provision of the therapeutic shoes and inserts must be reviewed and verified by the supervising physician. 5.16%
7. Documentation did not include an in-person supplier visit at the time of delivery that assessed the fit of the shoes and inserts with the patient wearing them. 4.84%
8. Documentation did not include a Statement of Certifying Physician. 4.52%
9. The Statement of Certifying Physician was signed more than three months prior to delivery of the shoes/inserts. 4.52%
10. The patient's medical records do not indicate the presence of one or more of the six conditions the Policy Article (A52501)External Website specifies must be present in order for the patient to meet coverage criteria for therapeutic shoes. 3.55%

*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.

Resources:

Updated May 21, 2024

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