NHIC Announces Results of Q3 K0823 Prepayment Review

The Jurisdiction A DME MAC says it will continue its widespread prepayment review of K0823-coded power wheelchairs after announcing its third-quarter review results for 2011.

NHIC Corp. said 453 K0823 claims from 175 suppliers were initially involved in the third-quarter prepayment complex medical review. Those suppliers were then asked to submit additional documentation for the claims, which were reviewed by NHIC from July 1 through Sept. 30, 2011.

NHIC reported that it ultimately allowed 55 percent of claims that it reviewed after receiving additional documentation from suppliers, and denied 45 percent.

The Charge Denial Rate for Jurisdiction A K0823 claims subjected to widespread prepayment review in the second quarter of 2011 was 55.9 percent.

A major reason for denial, NHIC said, was insufficient documentation, including "insufficient clinical documentation to support medical necessity." Specific examples cited by NHIC included "clinical records (that) did not include medical documentation from the ordering clinician's face-to-face power mobility exam to substantiate that a patient is prevented from accomplishing mobility-related activities of daily living due to mobility deficits."

Other claims were denied because records did not detail why the beneficiary was at risk of injury or death while attempting to perform mobility-related activities of daily living; because face-to-face evaluations didn't include a comprehensive physical examination to clearly define the beneficiary's specific mobility limitations, such as range of motion and pain levels; and because clinical documentation did not discuss use or trials of alternative mobility devices.

Insufficient documentation was listed as a reason for denial in 31 percent of claims examined. Missing detailed product descriptions accounted for 16 percent of denials, while problems with the seven-element order accounted for 15 percent of denials.

Other issues noted by NHIC as reasons for denials included home assessment issues, such as missing evidence that an assessment was completed before or at the time the power chair was delivered; specialty exam issues, such as documentation that lacked financial attestation statements; and missing delivery tickets.

NHIC also reminded DME providers that if they repeatedly do not respond to requests for additional documentation related to the widespread K0823 prepayment review, they could be referred to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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