CGS Administrators, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor (DME MAC) announced the quarterly results of its widespread payment review of claims for Healthcare Common Procedure Coding System (HCPCS) code A-5500 (off-the-shelf depth-inlay shoe). The error rate for the fourth quarter of 2013 was 87 percent, and the allowed dollars error rate was 88 percent; in the previous quarter, the error rate was 82 percent, and the allowed dollars error rate was 81 percent. The A-5500 service-specific prepayment edit began in September 2010.
Responses to Additional Documentation Requests (ADRs) were not received for 15 percent of claims. According to the documentation received, the following are the top ten reasons for denial. The percentages reflect the fact that a claim could have more than one missing or incomplete item.
- Medical records from the certifying physician were not provided: 32 percent.
- The medical records did not include a clinical foot evaluation conducted by the certifying physician or conducted by another clinician (podiatrist, nurse practitioner, clinical nurse specialist, physician assistant, etc.) and approved, initialed, and dated by the certifying physician that documents the beneficiary had one of the six conditions the local coverage determination (LCD) specifies must be present in order to qualify for coverage: 26 percent.
- The supplier’s in-person evaluation of the beneficiary’s feet was missing one or both of the following required elements: Description of the abnormalities the shoes/inserts/modification need to accommodate; or measurements of the beneficiary’s feet: 15 percent.
- Documentation did not include a clinical foot exam: 13 percent.
- Delivery documentation was not received or was missing the name of the beneficiary, the delivery address, a description of the items, and/or the quantity delivered: 13 percent.
- The beneficiary’s medical records did not document the presence of one or more of the following conditions: Previous amputation of the other foot, or part of either foot; history of previous foot ulceration of either foot; history of pre-ulcerative calluses of either foot; or peripheral neuropathy with evidence of callus formation of either foot; foot deformity of either foot; or poor circulation in either foot: 10 percent.
- Documentation provided by the supplier did not include a copy of a detailed written order: 9 percent.
- Documentation did not include a copy of an in-person session with the supplier at the time the shoes were delivered to the beneficiary to assess the fit of the shoes and inserts with the beneficiary wearing them: 8 percent.
- The foot exam provided insufficient detail to verify that the beneficiary had one of the six qualifying conditions: 8 percent.
- The supplier’s delivery evaluation did not document that, with the beneficiary wearing the shoes and inserts, the supplier assessed that the shoes/inserts/modifications fit properly: 7 percent.
For more information, visit the CGS website and access the
Therapeutic Shoes Documentation Resources.