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

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2012-12 Results of Widespread Prepayment Review of Claims for HCPCS K0823

December 20, 2012

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)

Historical Review Results
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 April 01, 2012 through June 30, 2012, and resulted in a 62.3.7% percent Charge Denial Rate (CDR).

Current Review Results
DME MAC Jurisdiction A has completed the widespread prepayment review of claims for Power Wheelchairs (HCPCS code K0823). These findings include claims with dates processed from July 1, 2012 through September 30, 2012. This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor.

This review involved prepayment complex medical review of 543 claims submitted by 203 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 112 (20%) of the ADR requests issued. Of the 431 claims for which responses were received, 87 of the claims were allowed and 344 of the claims were denied. This resulted in a claim denial rate of 79.8%. 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 72.4%.

Charge Denial Rate Historical Data
The following graph depicts the Charge Denial rate from previous quarters to current:

Charge Denial Rate Quarter
2011 Qtr 4 49.8%
2012 Qtr 1 54.7%
2012 Qtr 2 62.3%
2012 Qtr 3 72.4%

Primary Reasons for Denial
Based on the review, the following are the primary reasons for denial. Note that the percentages below reflect the fact that a claim could have more than one missing/incomplete item.

Face to Face Clinical Evaluation Documentation Issues

35% of the denied claims were missing required clinical documentation and medical records to support medical necessity. These claims did not meet the coverage criteria outlined in the K0823 Local Coverage Determination, L21271.
Documentation available from the mobility exam was insufficient and did not include a comprehensive Face to Face Clinical Evaluation by the treating physician that objectively addresses the patient’s mobility limitations and provided a clear picture of the patient’s mobility deficits. Sufficient objective measurements were also not provided.
The Supplier Generated Template provided failed to capture enough comprehensive information and provide additional medical information to demonstrate the reasonable and necessary requirement for the Power Wheelchair requested. No comprehensive narrative clinical documentation was received which reflects a clear understanding of the beneficiary’s mobility with measured recordings of patient’s upper and lower extremity strength and range of motion.
Clinical documentation was insufficient as it did not address historical perspective of the patient’s mobility issues and the prior use of other mobility assistive devices.
The Face to Face Clinical Evaluation documentation provided did not clearly indicate that the reason for the visit was a mobility evaluation.
8% of the denied claims had a Face to Face date listed on the 7 Element Order that did not match the date of the Face to Face Clinical Evaluation.
3% of the denied claims did not have the treating physician’s signature and/or the treating physician’s signature date on the Face to Face Clinical Evaluation.
3% of the denied claims did not have the treating physician’s signature in concurrence with the specialty exam.
7 Element Order Issues

2% of the denied claims did not include a 7 Element Order.
16% of the denied claims were incomplete, missing one or more of the required elements.
7% of the denied claims did not include confirmation the supplier received a copy of the Face to Face Clinical Evaluation within 45 days of the completion of the Face to Face exam; as verified by a supplier date stamp or equivalent.
2% of the denied claims have the 7 Element Order and the Detailed Product Description on the same form.
1% of the denied claims have the 7 Element Order dated prior to the completion of the Face to Face Clinical Evaluation.
1% of the denied claims had an illegible 7 Element Order.
Detailed Product Description Issues (DPD)

10% of the denied claims did not include a Detailed Product Description.
7% of the denied claims had an incomplete Detailed Product Description.
13% of the denied claims had the Detailed Production Description dated prior to the physician’s signature on the 7 Element Order
1% of the denied claims did not have the treating physician’s signature and/or the treating physician’s signature date on the Detailed Product Description
1% of the denied claims had an illegible Detailed Product Description.
Proof of Delivery Issues

5% of the denied claims did not include Proof of Delivery.
8% of the denied claims had Proof of Delivery that did not match the claim date of service.
LCMP Specialty Exam issues

17% of the denied claims did not include financial attestation statement stating the LCMP provider did not have a financial relationship with the supplier providing the wheelchair.
Home Assessment Issues

10% of the denied claims did not include evidence of a home assessment being completed before or at the time of the delivery of the Power Wheel Chair, (PWC).
6% of the denied claims had home assessments that were not signed and dated by either the supplier or the practitioner.
Claim Examples
As an additional educational measure, the following are actual examples of claim denials. NHIC expects that these examples will assist suppliers in understanding the medical review process and the documentation errors that occur with K0823 claims:

Example 1

Received: Documentation provided in this claim included: the Specialty Evaluation, the Proof of Delivery, the 7 Element Order, and the Detailed Product Description.

Missing: Home Assessment and Financial Attestation. The documentation provided was missing the Face to Face Clinical Evaluation by ordering physician. The Detailed Product Description did not include the manufacturer name and model number of the specific wheelchair base. Reviewer was unable to determine what type of wheelchair was requested. The date of the Face to Face Clinical Evaluation was incorrect on the 7 Element Order. The date the ordering physician signed the LCMP Specialty Evaluation was not listed as the Face to Face date on the 7 Element Order.
Example 2

Received: Documentation provided in this claim included: the 7 Element Order, the Face to Face Clinical Evaluation by treating physician, and the Detailed Product Description

Missing: Home Assessment and Proof of Delivery. The documentation provided did not include a Home Assessment performed by a supplier representative. Proof of Delivery was not included in the submitted documentation.
Example 3

Received: Documentation provided for this claim included: the 7 Element Order, the Home Assessment, the Proof of Delivery, the Face to Face Clinical Evaluation by treating physician, and the Detailed Product Description.

Missing: Face to Face Clinical Evaluation by treating physician is missing narrative which clearly indicates the major reason for the visit was a mobility examination. The Detailed Product Description did not have a narrative description of the manufacturer name and model name/number of the specific wheelchair base requested in the claim.
Next Step
Based on the results of this prepayment review, DME MAC A will continue to review claims billed with HCPCS K0823.

Suppliers are reminded that repeated failure to respond to ADR requests could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.

Educational References
NHIC Corp. DME MAC and CMS provide extensive educational offerings related to the proper documentation requirements for K0823 claims. Please ensure that the responsible supplier staff is aware of and references this educational material so that supporting documentation for your claims is compliant with all requirements:

CERT Error Articles

Power Mobility Devices (L21271) LCD

Power Mobility Devices – 7-Element Order (published 11/05/09)

Power Mobility Devices Billing Reminder (published 01/11/08)

DME MAC Jurisdiction A Supplier Manual (Chapter 10 – Durable Medical Equipment) for additional information regarding coverage and documentation requirements

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) (published 9/28/12, published 07/13/12, published 04/20/12, published 12/15/11, published 08/26/11, published 06/10/11, published 03/11/11, published 11/05/10)

Frequently Asked Questions (search word PMD)

Power Mobility Devices (PMDs) Complying with Documentation & Coverage Requirements (Medicare Learning Network; ICN 905063 September 2011)

Power Mobility Device Face-to-Face Examination Checklist (SE1112)