REIMBURSEMENT & CODINGNEWS
First Quarter Edit Effectiveness for Therapeutic Shoes Review
The Jurisdiction D DME MAC Medical Review Department is conducting a widespread complex review of HCPCS codes A5500 . The first quarter edit effectiveness results from September 2011 through December 2011 are as follows :
This review identified 214 claims of which 207 were denied . A total of 42 claims were denied for no response to the additional documentation request . This resulted in an overall error rate of 97 %. Due to this high error rate , NAS will continue with the widespread complex review .
The following are the top reasons for denial :
A . Criterion 2 was not met per Policy Article ( PA ) A37076
B . Criterion 3 was not met per PA A37076
C . Requested documentation was not provided within the allotted time frame as referenced in the Medicare guidelines
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
An in-depth explanation of the denial reasons are as follows :
A . 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 .
b .
Previous amputation of the other foot , or part of either foot , or
History of previous foot
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Current Pedorthics May | June 2012 45