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2019 Quarterly Status Report – HCPCS Codes A5500, A5512, A5513

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows:

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 The file does not include medical records from the certifying physician. Refer to A52501. 35.15%
2 The medical records do not verify that the certifying physician is managing the patient's diabetes. Refer to A52501. 23.33%
3 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 Determination specifies must be present for coverage. Refer to A52501. 23.03%
4 The medical records do not include a foot examination. Refer to A52501. 17.88%
5 The examination documenting the medical management of the patient's diabetes may only be performed by a doctor of osteopathy (D.O.) or medical doctor (M.D.). Refer to A52501. 11.52%
6 The supplier's delivery evaluation did not document that the supplier assessed, with the beneficiary wearing the shoes and inserts, that the shoes/inserts/modifications fit properly. Refer to A52501. 10.61%
7 The detailed written order is missing the date of the order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 10.00%
8 The documentation does not include a detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 7.27%
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. Refer to A52501. 6.06%
10 The detailed written order is missing the physician's signature. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 5.76%

Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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