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 July 1 – September 30, 2024. The error rate for this quarter is 33.45%. 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 covered conditions. | 26.52% |
2. | The file does not include medical records from the certifying physician. | 9.32% |
3. | The examination documenting the medical management of the patient's diabetes may only be performed by a D.O., M.D., or nurse practitioner (NP) or physician assistant (PA) practicing “incident to” the supervising physician’s authority. NP or PA notes about the provision of the therapeutic shoes and inserts must be reviewed and verified by the supervising physician. | 8.24% |
4. | The documentation does not have a valid order. | 6.81% |
5. | The statement of certifying physician is dated prior to a documented visit with the certifying physician. | 5.73% |
6. | The supplier billed for custom inserts (A5513) but the supplier in-person shoe selection evaluation did not include documentation that the supplier took impressions, made casts, or obtained CAD-CAM images of the beneficiary's feet to be used in creating positive models of the feet. | 4.66% |
7. | 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. | 3.94% |
8. | The statement of certifying physician did not show that the beneficiary had one or more of the 6 covered foot conditions. | 3.94% |
9. | The supplier in-person shoe selection evaluation did not include measurements of the beneficiaries’ feet. | 3.58% |
10. | Documentation did not include a statement of certifying physician. | 3.58% |
*The total percentage will be greater than 100% because some claims 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 be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
- 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: November 5, 2024