National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review department has provided a summary of results of its ongoing prepayment targeted medical review (TMR) of therapeutic shoes for persons with diabetes. The following is based on a selection of multiple supplier-submitted claims based on a targeted service(s) that were reviewed for medical necessity.
Additional documentation was requested from July 1, 2012, to September 30, 2012. Of the 258 claims reviewed, 246 were denied, indicating a claims error rate of 95 percent. The top two reasons for denial:
- No documentation received – 22 percent
- Denied as not medically necessary – 63 percent
The top issues contributing to these denials are:
- No response was received to the additional documentation request (ADR) letter within the required timeframe.
- Medical record from treating physician failed to document sufficiently the qualifying foot condition.
- Certifying statement was not received.
- No detailed order was received prior to billing.
- Pricing, Data Analysis, & Coding Contractor (PDAC)-information on shoes and/or inserts was not provided.
- Proof of delivery was not provided.
NGS said that it is important for suppliers to be familiar with the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD) (L27040) and Policy Article (A47129), which can be reviewed at the NGS Medical Policy Center. Additional resources and articles, as well as documentation requirements, are available at www.ngsmedicare.com
