| NHIC, Corp.DME MAC A ListServe | For Immediate Release |
| August 26, 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. This review was initiated based on the result of the widespread pre-payment probe review initially performed by TriCenturion, which determined the Charge Denial Rate (CDR) to be 89.75% for Jurisdiction A. Subsequently, all HCPCS K0823 claims continued to be subjected to pre-payment review.DME MAC A recently concluded subsequent quarterly widespread pre-payment reviews. This process involves the selection of random claims, for which an ADR (automated development response) letter is issued to the supplier requesting medical documentation. The documentation received is reviewed by clinical staff for compliance with Medicare rules and regulations.The results of the quarterly review for claims from October 1, 2008 through December 31, 2008, identified the following CDR:This review involved 105 claims submitted by 30 suppliers, of which, 34 claims were allowed and 71 were denied (67.62%). This resulted in an overall Charge Denial Rate of 67.62%, calculated by dividing the denied allowed amount ($285,682.70) by the total reviewed allowance amount ($422,488.50).The results of the quarterly review for claims from January 1, 2009 through March 31, 2009 identified the following CDR:This review involved 348 claims submitted by 125 suppliers, of which 129 claims were allowed and 219 were denied (69.93%). This resulted in an overall Charge Denial Rate of 62.78%, calculated by dividing the denied allowed amount ($860,235.86), by the total reviewed allowance amount ($1,370,260.30).These reviews determined the primary reasons for denials were:Mobility-related activities of daily living (MRADLs) limitations are not provided in detail. Documentation should identify specific limitations and clearly indicate what they can and cannot complete in terms of MRADLs. Beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home in order to perform his/her MRADLs during a typical day. Documentation should provide details, such as;Strength levels and degrees of range of motion (ROM) of the beneficiary's upper and lower extremities.Endurance level.Pain rating and how performance of MRADLs impacts this pain rating. Supplier Generated Reports:Face-to-Face mobility examination forms do not record a complete medical examination, they do not provide enough detail information to adequately describe the medical necessity for the power mobility device.Many of the face-to-face examination and medical necessity/justification letters are check mark box template forms which are vague in the areas addressed with no detailed objective documentation to support the items marked. Data on forms have also been noted to conflict from page to page and/or document to document. Sequence of Events have been out of order:Detailed product description document is dated prior to seven element order / prescription.Seven element order / prescription, signed by physician but not dated.Letter of medical necessity / justification dated after detail product description.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.Suppliers are reminded to reference the following publications for documentation requirements. The January 11, 2008 educational article Power Mobility Devices Billing Reminder at http://www.medicarenhic.com/dme/articles/011108_pmd.pdf and the Power Mobility Devices (L21271) LCD at http://www.medicarenhic.com/dme/medical_review/mr_lcd_current.shtml. |
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