NGS: Establishing Medical Necessity Is Still a Problem for Reviewed Power Chair Claims

Establishing medical necessity for power wheelchair claims under widespread prepayment review is still a major difficulty, National Government Services (NGS) said, as it released 2013 second-quarter results.

The ongoing prepayment review focuses on Group 2 power wheelchairs without the ability to accommodate an additional powered seating option, NGS said in its announcement. The review involves HCPCS codes K0820-K0829. Related power chair accessories are also included in the review.

From April 1 to June 30, NGS - Medicare's Jurisdiction B DME MAC - processed 811 claims for K0820-K0829 power bases and accessories. Of that total, 754 were developed for additional documentation.

NGS says it approved 234 of the claims in full, while partially or fully denying the rest. That resulted in a 64-percent claims error rate.

"The most common reason for claim denials was that the physical and functional findings that were documented in the medical records failed to clearly establish medical necessity for power mobility," NGS said in its announcement. "The information submitted failed to prove a beneficiary was unable to walk or propel an optimally configured manual wheelchair to resolve limitations significantly impairing mobility-related activities of daily living inside the home."

The DME MAC said this difficulty was "consistent with previous quarterly analyses."

In addition, some claims - 57 in the second quarter -- were automatically denied because the suppliers who filed the claims failed to provide additional documentation as requested.

About the Author

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

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