Funding Essentials

K0823 Claims Denied at Alarming Rates

The recent publication of the DME MAC Jurisdiction A prepayment review results for K0823 power wheelchairs shows there is still plenty of confusion with regard to the documentation requirements for power mobility devices (PMD).

The last four quarterly results have shown overall denial rates of 67.62 percent, 62.78 percent, 71.74 percent and 87.27 percent, respectively. This is alarming because the PMD policy has been in place for three years now, and the rate of denial does not appear to be getting any better.

Additionally, the reasons for denial have remained essentially the same: No information pertaining to mobility limitations, insufficient details for why the patients cannot function with lesser equipment, supplier-generated forms, incomplete “7-element” orders and sequences of events that are out of order.

The Challenges of Securing K0823 Documentation

The policy is pretty straightforward in stating what the requirements are for coverage of power mobility devices. However, with the onus for adequate documentation being placed on physicians who have nothing at stake, it is extremely difficult to gather the necessary information.

The process is so labor intensive that everyone is looking for ways to cut corners and simplify things. Unfortunately, there are no shortcuts to the documentation guidelines for PMDs. The best solution is to educate the physicians on the proper information necessary to meet the coverage criteria. Here is an outline of some of the obstacles physicians and suppliers have to contend with, along with some suggested resolutions.

Explain the Client’s Mobility Limitations in Detail

Mobility limitations are the primary reason someone needs a power mobility device, so it is crucial to make sure this information is documented in all face-to-face exams.

Physicians should list the patient’s mobility limitations specifically and indicate what they can and cannot do in terms of mobility-related activities of daily living (i.e., bathing, dressing, feeding, grooming and toileting). Without this documentation on file, the coverage criteria are not met.

An example might be an explanation as to how the patient’s arthritis, congestive heart failure and shortness of breath prevent them from getting to the bathroom in adequate time.

Eliminate the Viability of Using Lesser Equipment

It is also important for the physician to state why the patient is unable
to use lesser equipment. Specific statements need to be made about why the patient cannot use a cane, a
walker or a manual wheelchair.

Documentation should include information about upper- and lowerextremity strength levels and range of motion, the patient’s endurance and pain rating, and how the performance of MRADLs impacts these measurements. Inferences are not always made based on the patient’s diagnosis, so if someone is a double below-knee amputee, it does not preclude the physician from documenting why the patient cannot use a cane or a walker.

This issue is particularly troublesome to physicians because they view such statements to be redundant and unnecessary based on the patient’s diagnosis.

Supplier-Generated Forms vs. Official Documentation Requirements

The next issue creating denials is the use of forms to document the face-toface examination.

Some suppliers provide forms for the physician to complete, giving the false impression that these documents are a sufficient record of the face-to-face visit and medical evaluation. Even if the physician completes this type of form and includes it in the patient’s medical record, it does not provide sufficient documentation of a comprehensive assessment of the patient’s mobility needs.

It is essential that physicians be aware of this, because if they complete a form, it is still expected that there be notes about the visit in the patient’s medical records to substantiate the information on the form. So to be compliant with the policy, those suppliers using forms would be asking the physician to document the face-to-face exam twice: once on the form and once in the medical record.

We all know this does not happen, but that is the only way a form can be used within the guidelines. To keep it simple and consistent, the physician should document the results of the face-to-face exam in the same format that he or she uses for other entries in his or her patient medical records.

Getting the 7 Elements Correct

An incomplete “7-element” order is the next culprit producing denials for PMDs. All 7 elements are required to meet the coverage guidelines; one missing element is enough to spoil an otherwise good claim.

The 7 elements required are as follows:

  • patient name
  • description of the item ordered
  • date of the face-to-face exam
  • diagnoses pertinent to the need for a PMD
  • length of need
  • physician signature
  • date of physician signature

The element that is overlooked most often is the date of the face-to-face exam. The reason for this is that the physician typically signs the order on the same date as the face-to-face exam and thinks the date of his/her signature should also suffice as the face-to-face date. So it is very important to make sure there are two separate dates on the 7-element order, even if it is the same date twice.

Additionally, forms with check-off boxes that identify specific types of equipment for the physician to select are not an acceptable format. No part of the 7-element order can be completed by the supplier.

Timing Is Crucial

Lastly, there is a specific sequence in which the events leading up to delivery of a PMD must take place. The face-to-face exam must take place first, regardless of the circumstances, followed by the 7-element order. The order can be written on the same day as the face-to-face exam, but not before.

Once these are complete, the supplier must generate a detailed product description to be signed by the physician and must perform a home assessment prior to or at the time of delivery.

Watch for these issues, correct them up front and your denials should become a thing of the past.

This article originally appeared in the January 2010 issue of Mobility Management.

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