NHIC Reports Q4 Results of K0823 Prepayment Review

• By Laurie Watanabe
• Apr 18, 2012

NHIC Corp., the Jurisdiction A DME MAC, has reported the latest results of its widespread prepayment review of Group 2 standard power chairs.

For the fourth quarter of 2011, NHIC reported an overall charge denial rate of 49.8 percent. That compares to a 52.5-percent charge denial rate for Group 2 standard power chair claims received in the third quarter last year.

NHIC reviewed 403 claims containing the K0823 HCPCS code, from 127 different suppliers. The K0823 code comprises Group 2 standard power chairs with captain's seats and a patient weight capacity up to and including 300 lbs.

NHIC issued requests for additional documentation for the claims being reviewed, but said it did not receive it for 92 of the claims.

Among the claims that were backed up by additional documentation, NHIC said 51.7 percent of the claims were allowed, while 48.3 percent of the claims were denied.

Insufficient documentation was the leading cause of denial for quarter four claims that were reviewed. NHIC said examples of insufficient clinical documentation included failure to address trials of other types of mobility equipment; missing face-to-face examinations between beneficiaries and physicians; and lack of narrative clinical documentation that explained upper- and lower-extremity strength and range of motion along with patient statistics.

In other documentation-related cases, NHIC said, the beneficiary's stated weight exceeded the capacity of the K0823 power chair provided.

Insufficient documentation accounted for 32 percent of denials, NHIC said. Other documentation errors included missing physician signatures on the specialty evaluations; missing detailed product descriptions; missing proof of delivery; lack of seven-element orders; and lack of home assessments.

Meanwhile, problems with detailed product descriptions accounted for 17 percent of denials. Some claims did not include a detailed product description at all, while others were missing date stamps or had incomplete or incorrect HCPCS codes.

NHIC also cited problems with seven-element orders, including illegible documents, missing dates for the face-to-face exams, and missing provider and/or physician signatures.

"Based on the results of this prepayment review," NHIC said, "DME MAC A will continue to review claims billed with HCPCS K0823."