Noridian Administrative Services (NAS), the Jurisdiction D DME MAC Medical Review Department, recently conducted a widespread service-specific probe complex review of HCPCS code A5500 (off-the-shelf depth-inlay shoe) and A5512 (multiple density inserts). This review was based on CERT review analysis. One hundred claims from 91 suppliers, taken from March 2011 to July 2011, were used as a sample in the review. The review revealed that 98 of these 100 claims contained errors, which calculates to an overall "error ratio" of 97 percent. Because the error rate remains high, NAS plans to conduct a widespread complex review.
The following is a summary of claims reviewed during the probe, including determinations made and primary reasons for denial:
- 2 claims were paid;
- 98 claims were denied in full for the following reasons per LCD L157 and Policy Article A37076:
- 63 claims were denied for not meeting criterion 3;
- 62 claims were denied for not meeting criterion 2;
- 35 claims were denied for not meeting criterion 4;
- 33 claims were denied for not meeting criterion 1; and
- 24 claims were denied for no documentation received in response to the ADR letter request within the 30-day requirement.
The total claim volume totals more than 100, as some of the claims have multiple errors.
Per Policy Article A37076 and LCD L157:
The patient has diabetes mellitus (ICD-9 diagnosis codes 249.00-250.93).
The certifying physician has documented one or more of the following conditions in the patient's medical record:
Previous amputation of the other foot, or part of either foot or
History of previous foot ulceration of either foot or
History of pre-ulcerative calluses of either foot or
Peripheral neuropathy with evidence of callus formation of either foot or
Foot deformity of either foot or
Poor circulation in either foot; and
The certifying physician has noted that indications (1) and (2) are met, that he/she is treating the patient under a comprehensive plan of care for his/her diabetes, and as part of this treatment, the patient needs diabetic shoes/inserts. For claims with dates of service on or after 1/1/2011, the certifying physician must:
Examine the patient during an in-person visit, in which diabetes management is addressed within six months before the shoes/inserts are delivered; and
Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within three months before the shoes/inserts are delivered.
Before selecting what items the patient needs, the supplier must conduct and document an in-person evaluation of the patient. (For more information, review the related Local Coverage Determination, Documentation Requirements section.)
Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R §424.516[f]) state that a supplier is required to maintain documentation for seven years from the date of service and, should a CMS or a Medicare contractor request it, provide access to that documentation. Failing to provide records may result in denial of a claim and referral to the National Supplier Clearinghouse (NSC).
Suppliers should be familiar with the documentation requirements and utilization parameters outlined in the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD) and Policy Article. Suppliers can also review the therapeutic shoes documentation checklist.
In addition, providers can review resources on therapeutic shoes and inserts.
For information on probe/error validation reviews, review CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3.
Suppliers can access all of the Jurisdictional DME MAC LCDs, Policy Articles and other resources on the Information for DMEPOS Suppliers section of PFA’s website.