Noridian [Jurisdiction D DME-MAC] conducted an edit for Therapeutic Shoes Review from June 2012 through August 2012. The review identified 2,846 claims for HCPCS code A5500 of which 2,635 were denied.
A5500 – FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION
AND SUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE
MULTI- DENSITY INSERT(S), PER SHOE
Due to this high error rate, NAS will continue with the widespread complex review. Please be aware of the clinical documentation requirements outlines below as reasons for the denials
The following are the top reasons for denial:
A. Criterion 2 was not met per Policy Article (PA) A37076
Policy states: There must be documentation to support that the certifying physician has documented in the patient’s medical record one or more of the following conditions:
a. Previous amputation of the other foot, or part of either foot, or
b. History of previous foot ulceration of either foot, or
c. History of pre-ulcerative calluses of either foot, or
d. Peripheral neuropathy with evidence of callus formation of either foot, or
e. Foot deformity of either foot, or
f. Poor circulation in either foot;
In order to meet criterion 2, the certifying physician must either:
g. Personally document one or more of criteria a – f in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or
h. Obtain, initial/sign, date (prior to or on the same day as signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a – f.
Note: The certification statement is not sufficient to meet the requirement for documentation in the medical record.
B. Criterion 3 was not met per PA A37076
Policy States: There must be documentation to support that the certifying physician has certified that indications (1) and (2) are met and that he/she is treating the patient under a comprehensive plan of care for his/her diabetes and that the patient needs diabetic shoes.
For claims with dates of service on or after 1/1/2011, the certifying physician must:
- Have an in-person visit with the patient during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
- Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.
Note: Per Policy Article A37076 the Certifying Physician is defined as a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care. The certifying physician may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.
C. Requested documentation was not provided within the allotted time frame as referenced in the Medicare guidelines
A large number of suppliers failed to respond to our request for records.
Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the NSC.
D. There was no documentation from the supplier to support an in-person visit at the time of delivery per Local Coverage Determination (LCD) L157 and PA A37076
There must be documentation from the supplier to support an in-person visit at the time of delivery. The supplier must conduct and document an in-person visit with the patient. The in-person evaluation of the patient by the supplier at the time of delivery (refer to related Policy Article, Non-Medical Necessity Coverage and Payment Rules, criterion 5) must be conducted with the patient wearing the shoes and inserts and must document that the shoes/inserts/modifications fit properly.