NHIC, Corp.
DME MAC A ListServe For Immediate Release
November 19, 2009
Results of Widespread Prepayment Review of Claims for HCPCS K0823, (Power Wheelchair, Group 2 Standard, Captain’s Chair, Capacity Up to and Including 300 Pounds)
DME MAC A continues its widespread, pre-payment review of Power Wheelchairs, HCPCS K0823, based on the results of previous quarterly widespread pre-payment probe reviews findings. The claims covered the period from October 01, 2008 through December 31, 2008 and resulted to a 67.62% Charge Denial Rate (CDR). Quarterly review findings for the period covering claims from January 01, 2009 through March 31, 2009 resulted to a 62.78% CDR. Based on the high CDR, all claims billed with HCPCS K0823 continue to be the subject of a pre-payment review.
DME MAC A recently concluded 2 additional quarterly pre-payment reviews. The results of the quarterly review for claims paid from April 01, 2009 through June 30, 2009, identified the following CDR:
This review involved 510 claims submitted by 95 suppliers, of which, 148 claims were allowed and 362 were denied (70.98%). This resulted in an overall Charge Denial Rate of 71.74%
Based on review of the documentation received, the following are the primary denial reasons.
Determined to be medically unnecessary (50.0%) (examples)
Face to Face; not a physical exam; did not address mobility issue; not signed by physician
Upper extremity issues not addressed or ROM and strength indicated did not justify PWD
Documentation illegible
No objective findings and/or insufficient clinical findings to justify need of PWD
Indication patient able to walk
Indication patient in SNF
Forms determined to be supplier generated pre-printed forms (39.5%) (examples)
7 element partially supplier completed
Mobility Evaluation supplier formatted check off list
Face to Face supplier formatted questionnaire, not a comprehensive examination
Incomplete 7 element order (5.52%)
The results of the quarterly review for claims paid from July 01, 2009 through September 30, 2009 identified the following CDR:
This review involved 299 claims submitted by 60 suppliers, of which 46 claims were allowed and 253 were denied (84.62%). This resulted in an overall Charge Denial Rate of 87.27%
Based on review of the ADR documentation received, the following are the primary denial reasons.
Determined to be medically unnecessary (62.06%) (examples)
Face to Face evaluation; not a physical exam; did not address mobility problems
Upper extremity issues not addressed or ROM and strength indicated did not justify PWD
No objective findings and/or insufficient clinical findings to justify need of PWD
Documentation identified patient injury / surgery, PWD required for rehab / post op period
Forms determined to be supplier generated pre-printed forms (30.83%) (examples)
7 element partially supplier completed
Mobility Evaluation supplier formatted check off list
Face to Face supplier formatted questionnaire, not a comprehensive examination
Incomplete 7 element order (3.16%)
To justify the removal of a pre-payment edit, the error rate must reflect a reduction of 70 percent or more. Based on the above quarterly CDRs, DME MAC A will continue the current widespread prepayment review process of HCPCS K0823.