HCPCS Codes A5500, A5512 and A5513 – Service-Specific Pre-pay Review
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HCPCS Codes A5500, A5512 and A5513 – Service-Specific Pre-pay Review
Following shortly after DME MAC Region B's pre-payment review, the CIGNA Government Services,the Jurisdiction C DME MAC , will be implementing service-specific Medical Review edits for Healthcare Common Procedure Coding System (HCPCS) codes A5500 (FOR DIABETICS ONLY, FITTING [INCLUDING FOLLOW-UP], CUSTOM PREPARATION AND SUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI-DENSITY INSERT[S]) , A5512 (FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT) and A5513 (FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT'S FOOT).  These edits are the result of data demonstrating a high claims payment error rate for this product category.
Claims subjected to these edits will be developed for additional documentation.  Suppliers receiving a development letter should follow the instructions contained in the letter for the specific documentation requested.  Suppliers will be asked to submit documentation including, but not limited to:
1. Prescribing physician's detailed written order
2. Completed signed and dated statement from the certifying physician (physician managing the beneficiary's systemic diabetes condition) specifying that the beneficiary has diabetes and:
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,
and is being treated under a comprehensive plan of care for his/her diabetes, and needs diabetic shoes.
3. Relevant medical records where the certifying physician either personally documented that the beneficiary met one or more of criteria 2a – 2f or obtained documentation from another clinician documenting the beneficiary met one or more of criteria 2a – 2f and the certifying physician indicated agreement with the information by initialing and dating the record
4. Supplier in-person evaluation conducted prior to selection of items that documents an examination of the beneficiary's feet with a description of the abnormalities that will need to be accommodated by the shoes/inserts/modification
5. In-person visit, at the time of delivery, which assesses the fit of the shoes and inserts with the beneficiary wearing them
6. Delivery documentation with the beneficiary's name and address and the description of the items provided
7.Any other pertinent records.
Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify that the patient's condition meets coverage criteria for therapeutic shoes for persons with diabetes.  The source of these records may be a physician's office, hospital, nursing home, home health agency, wound clinic, etc. Evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier.
The information must be received within 30 days of the date of the letter or the claim will be denied.  Additional information on this and other documentation requirements for codes A5500, A5512 and A5513 may be found on the CGS Medical Review web site at http://www.cignagovernmentservices.com/jc/coverage/MR/index.html
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