GOVERNMENTAFFAIRS
Status Report for Quarter
3 2013: HCPCS Code
A5500 — Service-Specific
Prepayment Review
The Medical Review Department of CGS, the Jurisdiction
C DME MAC, began a service-specific prepayment edit
for HCPCS codes A5500 (off-the-shelf depth-inlay shoe) in
September 2010. This edit is the result of data demonstrating a
high claims payment error rate for this product category.
A summary report for claims reviewed between July 1, 2013
and September 30, 2013 shows that the current quarter denial
rate is 82% and the previous quarter rate was 79%. Further,
the allowed dollars error rate was reported at 81% versus 78%
last quarter. CGS reported that the Non-response Rate to
Additional Documentation Requests was 16%.
An analysis of the claim denials showed that the top 10 reasons
a determination was made not to pay the claim were:
1. 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.
2. The reviewer could not confirm that the certifying physician
was managing the beneficiary’s systemic diabetes condition
because the file did not include medical records from the
certifying physician.
3. The beneficiary’s medical records did not document the
presence of 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.
4. Documentation provided by the supplier did not include a
copy of a detailed written order.
5. Documentation did not include a copy of an in-person
session with the supplier, at the time the shoes were
delivered to the beneficiary, which assessed the fit of the
shoes and inserts with the beneficiary wearing them.
6. 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.
7. The medical records provided did not confirm that the
certifying physician was managing the beneficiary’s systemic
diabetes treatment plan.
8. The foot exam provided insufficient detail to verify that the
beneficiary had one of the six qualifying conditions.
9. The supplier’s in-person evaluation of the beneficiary’s feet
was missing one or both of the following required elements:
(1) Description of the abnormalities the shoes/inserts/
modification need to accommodate; or (2) Measurements of
the beneficiary’s feet.
10. Documentation did not include an in-person evaluation
of the beneficiary’s feet conducted by the supplier prior to
selection of the specific items billed.
A sample case study follows this article to demonstrate proper/
improper documentation practices and reasons for denial.
Case Study
T.D. – 74 year old male
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