Skip to Main Content

Print | Bookmark | Email | Font Size: + |

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 October 1 and December 31, 2023. The error rate for this quarter is 45.41%. 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 the Local Coverage Article for Therapeutic Shoes for Person with Diabetes(A52501)External Website specifies must be present for coverage. 17.58%
2. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items. 8.07%
3. 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. 8.07%
4. Documentation did not include a Statement of Certifying Physician. 7.20%
5. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section PDF. 6.34%
6. The file does not include medical records from the certifying physician. 5.19%
7. The Statement of Certifying Physician is dated prior to a documented visit with the certifying physician. 4.90%
8. The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 4.03%
9. 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. 4.03%
10. The medical records do not verify that the certifying physician is managing the patient's diabetes. 3.75%

*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.


Updated: February 2, 2024


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved