Therapeutic Shoes/Inserts for Diabetics Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A5500, A5512, and A5513 reviewed between October 1 and December 31, 2022. The error rate for this quarter is 63.96%. 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 1 of the 6 conditions the Local Coverage Determination (LCD) specifies must be present for coverage. | 15.17% |
2. | 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. | 6.74% |
3. | Medical records do not include a certifying physician clinical evaluation that discusses the management of the beneficiary's systemic diabetes condition within 6 months prior to shoe delivery. | 6.62% |
4. | The file does not include medical records from the certifying physician. | 6.37% |
5. | The in-person evaluation of the patient's feet is missing a description of the abnormalities the shoes/inserts/modifications will need to accommodate. | 5.93% |
6. | The medical records do not verify that the certifying physician is managing the patient's diabetes. | 4.81% |
7. | The author did not authenticate (handwritten or electronic) the medical record documentation. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. | 4.74% |
8. | The medical records do not include a foot examination. | 4.62% |
9. | Documentation did not include a Statement of Certifying Physician. | 4.06% |
10. | Documentation did not include a supplier's in-person evaluation of the patient's feet prior to selection of the specific items. | 4.06% |
*The total percentage will be greater than 100% because some claims were 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 represent an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Local Coverage Article for Therapeutic Shoes for Person with Diabetes – Policy Article (A52501)
- Local Coverage Determination for Therapeutic Shoes for Person with Diabetes (L33369)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Therapeutic Shoes for Persons with Diabetes Resources
- Medicare Claims Processing Manual
- Medicare Program Integrity Manual
Additional Education: