DME-MAC Review of Therapeutic Shoes Found 94% Error Rate

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.