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
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
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
Supplier-Generated Forms vs.
The next issue creating denials is the
use of forms to document the face-toface
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.