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April 16, 2021

Widespread Post-Pay, Service-Specific Review Announcement – HCPCS Codes A5500 and A5512-A5514

CGS's Medical Review staff will be conducting a complex post-pay, service-specific medical review of HCPCS codes A5500 and A5512-A5514 (Therapeutic Shoes/Inserts for Diabetics). This review will be conducted because data analysis revealed that Jurisdiction C's allowed dollars for HCPCS codes A5500 and A5512-A5514 were significantly above expected amounts. Additionally, the Therapeutic Shoes/Inserts for Diabetics policy group ranked within the top #20 in total Comprehensive Error Rate Testing (CERT) errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in federal law at SSA 1833 (e) and in federal regulation at 42 CFR 424.5(a)(6). Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Detailed written order
  2. Completed, signed, and dated statement from the certifying physician (physician managing the beneficiary’s systemic diabetes condition) specifying that the beneficiary has diabetes and at least one of the following:
    1. Previous amputation of the other foot, or part of either foot
    2. History of pervious foot ulceration of either foot
    3. History of pre-ulcerative calluses of either foot
    4. Peripheral neuropathy with evidence of callus formation of either foot
    5. Foot deformity or either foot
    6. Poor circulation in either foot and is being treated under a comprehensive plan of care for his/her diabetes and needs diabetic shoes
  3. Clinical evaluation, performed by the certifying physician within 6 months prior to delivery, that addresses the beneficiary’s diabetes management
  4. Relevant medical records where the certifying physician either
    • Personally documented that the beneficiary met one of more of the criteria 2a-2f
    • Obtained documentation from another clinician documenting that the beneficiary met one or more of criteria 2a-2f
  5. Records from a supplier in-person evaluation conducted prior to selection of items that documents an examination of the beneficiary’s feet with a description of the abnormalities that will need to be accommodated by the shoes/inserts/modification
  6. Records of an in-person visit, at the time of delivery, which assesses the fit of the shoes and inserts with the beneficiary wearing them
  7. Any other pertinent records

NOTE: Any ABN on file should be submitted with other requested documentation.


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