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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/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 51.87%. 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 18.94%
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. 7.34%
3. 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. 6.17%
4. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items. 6.02%
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. 5.43%
6. 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. 4.85%
7. 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. 4.26%
8. Documentation did not include a Statement of Certifying Physician. 4.26%
9. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4External PDF. 4.26%
10. The file does not include medical records from the certifying physician. 3.67%

*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:

Updated: February 2, 2024

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