HCPCS A5500 and A5512 - Notification of Prepayment Review
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HCPCS A5500 and A5512 - Notification of Prepayment Review
The NAS Jurisdiction D DME MAC Medical Review has announced that it will be initiating a widespread prepayment probe review of claims for HCPCS codes A5500 (For diabetics only, fitting including follow-up, custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multidensity insert (s) per shoe) and A5512 (Multiple density inserts, direct formed, molded to foot prefabricated).
Widespread reviews are used to determine the extent of potential problem areas across multiple suppliers.  This review is being initiated based on the results of Comprehensive Error Rate Testing (CERT) review analysis.
In order to evaluate compliance with Medicare coverage and coding rules, all suppliers billing Jurisdiction D for HCPCS codes A5500 and A5512 are subject to this review.  Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for specific information to determine if the item billed complies with the existing reasonable and necessary criteria.  Failure to supply the requested information within 30 days of the date on the letter will result in the claim being denied as not medically necessary.  The ADR letter will provide instruction for submitting documentation.
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD) L157 and Policy Article A37076.
Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3 by clicking here.
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