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) 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 3.3.2.4. | 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). | 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.
Resources:
- Therapeutic Shoes for Persons with Diabetes Documentation Checklist
- Therapeutic Shoes for Person with Diabetes – LCD (L33369)
- Therapeutic Shoes for Person with Diabetes – Policy Article (A52501)
- Therapeutic Shoes for Persons with Diabetes Medical Review Resources
Updated: February 2, 2024