Therapeutic Shoes/Inserts for Diabetic Persons 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 January 1 and March 31, 2022. The error rate for this quarter is 65.58%. 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 6 conditions that the local coverage determination (LCD) specifies must be present for coverage. | 16.03% |
2. | The in-person evaluation of the patient's feet is missing a description of the abnormalities the shoes/inserts/modifications will need to accommodate. | 8.42% |
3. | The file does not include medical records from the certifying physician. | 7.94% |
4. | The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to the Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. | 6.48% |
5. | 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. | 5.91% |
6. | The medical records do not verify that the certifying physician is managing the patient's diabetes. | 4.62% |
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. | 4.37% |
8. | The documentation does not contain a valid standard written order (SWO). Refer to the Standard Documentation Requirements A55426. | 3.48% |
9. | Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items. | 3.40% |
10. | The medical records do not include a foot examination. | 3.24% |
*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: