LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2016-07 Prepayment Targeted Review HCPCS A5500

KYDEX PRO

STRONGER SAFER

LEEDerGROUP.com

Therapeutic Shoes for Persons with Diabetes (HCPCS A5500) Notification of Service Specific Prepayment Targeted Review

Noridian Jurisdiction A, DME MAC, Medical Review will be initiating a service specific prepayment targeted review of claims for each of the following HCPCS code.

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, PER SHOE

Service specific targeted reviews are initiated to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas, as well as, problem areas identified by their own data analysis. This review is being initiated based on a high Comprehensive Error Rate Testing (CERT) error rate.

In order to evaluate compliance with Medicare coverage and coding rules, all suppliers billing Jurisdiction A for HCPCS codes listed above are subject to this review. Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following specific information to determine if the item billed complies with the existing reasonable and necessary criteria.
Treating physician’s dispensing and written order
Documentation from the certifying physician that meets LCD criteria
Documentation to support in-person visit/evaluation made by the supplier that meets LCD criteria
Statement of Certifying Physician for Therapeutic Shoes signed on or after the date of the in-person visit and within 3 months prior to the delivery of the shoes/inserts
Documentation from the prescribing physician (if applicable)
Proof of delivery
The Advance Beneficiary Notice of Noncoverage (if applicable)
Any other supporting documentation

Failure to supply the above requested information within 45 days of the date of the letter will result in the claim being denied. Please fax or mail the requested documentation and a copy of the ADR letter. The ADR letter provided will also 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) L33369 and Policy Article A52501 on the Active LCDs webpage.

Additional information, educational opportunities and training tools related to this product category are available in Education & Outreach.

Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3

Last Updated Jun 23, 2016