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)
Posted August 06, 2010 (MOB)
DME MAC A Medical Review continues to review Power Wheelchairs, HCPCS K0823, based on the results of previous quarterly findings. The previous quarterly findings covered the period from January 01, 2010 through March 31, 2010 and resulted in a 45.7% Charge Denial Rate (CDR).
DME MAC A recently concluded the quarterly review for claims paid from April 1, 2010 through June 30, 2010 and identified the following:
- This review involved prepayment complex medical review of 1000 claims submitted by 394 suppliers, of which, 237 claims were allowed and 763 were denied resulting in a claim denial rate of 76.3%. Consequently, the total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error) divided by the total allowance amount of services medically reviewed resulted in an overall Charge Denial Rate of 75.3%.
Based on review of the documentation received, the following are the primary reasons for denial:
- Incomplete documentation (78.9%)
o One or more document not provided; no 7 element order / prescription; no detail product description; no physician Face to Face examination / mobility evaluation; no home evaluation / assessment; no LCMP; no attestation of financial relationship.
o 7 element order / prescription missing one or more elements (date of face to face, length of need, description of item, etc.), pre-printed “power mobility device” already entered.
o Detail product description not signed or signature and/or date illegible, allowance amounts not included, dated prior to completion of face to face / mobility evaluation.
o No received date indicators on documents. - Determined to be medically unnecessary (16%)
o Face to Face; not a physical exam; did not address mobility issue; only attesting to agree with PT
evaluation;
o Upper extremity / lower extremity issues not addressed.
o ROM and strength indicated did not justify PMD.
o Insufficient documentation submitted to establish medical necessity for PMD.
o Patient appears to be able to ambulate, utilize walker and/or manual wheelchair. - Other (5.1%)
o Duplicate claim submission.
o Late claim filing.
o Wheelchair returned to supplier.
o Claim billed in error.
Based on the above quarterly CDR, DME MAC A will continue to review claims billed with HCPCS K0823.
Suppliers are reminded to reference the following publications for documentation requirements. The January 11, 2008 educational article Power Mobility Devices Billing Reminder, November 05, 2009 educational article Power Mobility Devices – 7-Element Order, and the Power Mobility Devices (L21271) LCD.