Source: https://www.noridiansmrc.com/current-projects/01-028/
Timestamp: 2020-06-03 02:13:19
Document Index: 401263213

Matched Legal Cases: ['§1861', '§1833', '§1833', '§1834', '§1834', '§1861', '§424']

01-028 Therapeutic Shoes for Diabetics Notification of Medical Review - Noridian - SMRC
01-028 Therapeutic Shoes for Diabetics Notification of Medical Review /
01-028 Therapeutic Shoes for Diabetics Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B therapeutic shoes for diabetics, billed on dates of service from July 1, 2018 through June 30, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
Therapeutic shoes for diabetics, also known as diabetic shoes, are specialized shoes and/or inserts that are intended to reduce the risk of skin breakdown in diabetics with pre-existing foot disease(s). Therapeutic shoes and inserts are covered under the therapeutic shoes for individuals with diabetes benefit (Social Security Act §1861(s) (12)). Therapeutic shoes and inserts are covered, by Medicare Part B, if qualifying criteria and conditions are met. In 2018, the CERT Medicare Fee-for-Service Improper payment report noted an improper payment rate of 73.2% for this service.
A5500: For the Diabetics Only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe
A5512: For Diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of ¼ inch material of shore A 35 durometer or 3/16 inch material or shore A 40 durometer (or higher), prefabricated, each
A5513: For Diabetics Only, multiple density insert, custom molded from model of patient’s foot, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
A5514: For Diabetics Only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden. Additionally, the specific requirements will aid in clarity on scope of review to allow the MAC redeterminations team to process the request accordingly and prevent overturning of correct decisions.
Written verbal/dispensing order (if applicable)
All pertinent medical record documentation to support therapeutic shoes are reasonable and necessary for persons with diabetes, including but not limited to:
Documentation to support the beneficiary has one or more of the following diabetic conditions:
A history of pre-ulcerative calluses of either foot
A history of previous ulceration of either foot
A signed physician certification statement to support the beneficiary needs therapeutic shoes/inserts under a comprehensive plan of care related to their diabetic condition
Documentation to support the shoes are fitted and furnished by a podiatrist or other qualified individual (such as a pedorthist or orthotist)
Documentation of an examination of the beneficiary’s feet to include description of the abnormalities that will be accommodated by the shoes and/or inserts
Measurements of the beneficiary’s feet
Documentation of an evaluation, at time of delivery, to include an assessment with the beneficiary wearing the shoes and/or inserts and documentation to support the shoes and/or inserts fit properly
Advanced Beneficiary Notice (if applicable)
Any and all other documentation to support the item(s) billed
Social Security Act (SSA), Title XVIII, §§1833(e). Payment of Benefits
SSA, Title XVIII, §§1833(o). Payment of Benefits
SSA, Title XVIII, §§1834(j)(2)(B). Special Payment Rules for Particular Items and Services
SSA, Title XVIII, §§1834(j)(5)(iii). Special Payment Rules for Particular Items and Services
SSA, Title XVIII, §§1861(s)(12). Miscellaneous Provisions
42 Code of Federal Regulations (C.F.R.) §424.5(a)(6). Basic Conditions
CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 140. Covered Medical and Other Health Services
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2. Rules Concerning Orders
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7. Documentation in the Patient’s Medical Record
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.8. Supplier Documentation
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.9. Evidence of Medical Necessity
Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01, Chapter 1, Section 10.3. Supplementary Medical Insurance (Part B) – A Brief Description
Local Coverage Determination (LCD) L33369. Therapeutic Shoes for Persons with Diabetes. Effective October 1, 2015-present.
Local Coverage Article A52501. Therapeutic Shoes for Persons with Diabetes. Effective October 1, 2015-present
Local Coverage Article A55426. Standard Documentation Requirements for All Claims Submitted to DME MACs. Effective January 1, 2017-present