NHIC Describes CERT Errors on Wheelchair Claims

NHIC Corp., the Jurisdiction A DME MAC, has published new examples of claims, including several involving wheelchairs, that were reviewed and denied by the Comprehensive Error Rate Testing (CERT) contractor.

NHIC added that the examples chosen, from December 2012, represent the most common CERT errors.

The first example involves a claim for a Group 2 heavy-duty power wheelchair, HCPCS coded K0824-RR-KI. NHIC says in this case, it received the seven-element order, the detailed product description and a home assessment. The supplier also provided a physician's mobility evaluation that stated the Medicare beneficiary weighed 305 lbs., with a below-the-knee amputation of his left leg and an above-the-knee amputation of his right leg. The physician recorded the beneficiary's bilateral arm strength as 4 of 5.

The supplier who filed the claim also submitted a seating evaluation completed by an occupational therapist (OT).

But the CERT contractor objected to the following missing items:

-- A legible date stamp on the seven-element order.

-- A detailed product description.

-- The physician's mobility evaluation and the OT's mobility evaluation, "which was part of the face-to-face exam."

-- An authenticated mobility evaluation.

-- Documentation supporting a change in condition and why a Group 2 power wheelchair was required.

-- The physician's statement of concurrence of the OT's mobility evaluation.

In a second example provided by NHIC, the supplier filed a claim for a Group 2 heavy-duty power chair with captain's seating (K0825-RR-KJ) and a pair of elevating legrests (K0195-RR-KJ).

The supplier also provided a detailed product description, a seven-element order, proof of delivery, a home evaluation, a "template of Texas Academy of Family Physicians' mobility exam," and a progress note that "does not address mobility-related deficits."

For this claim, NHIC says, missing items included documentation to support the beneficiary's weight, documentation of previous use or trials of other mobility aids, and - since the chair in question was a rental -- documentation that supported the beneficiary's continued need for a power chair.

Also missing: "Treating physician's adequate documentation, using objective language, in the face-to-face mobility evaluation to support that the beneficiary has a mobility limitation that significantly impairs the ability to participate in [mobility-related activities of daily living] that cannot be sufficiently resolved by use of a cane, walker, manual wheelchair, optimally configured manual wheelchair or [power-operated vehicle]."

A claim for a high-strength lightweight manual wheelchair (HCPCS code K0004) was flagged by the CERT contractor because of missing documentation that should have proved the beneficiary's mobility limitations interfered with mobility-related activities of daily living, and could not be resolved by use of a lesser mobility device, such as a cane, walker or standard manual wheelchair, NHIC said. The claim also needed to include documentation on why the beneficiary required "a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi wheelchair."

The claim also neglected to include documentation to show the beneficiary's home would allow "adequate access between rooms, maneuvering space and surfaces for use of the manual wheelchair."

A second example of a denied manual wheelchair claim - this one for a K0001 rental - showed the supplier provided a clinician's note stating that the beneficiary was diagnosed with COPD. A physical therapist added that the beneficiary could ambulate 100 feet using a rolling walker and with a caregiver's assistance, and that the beneficiary needed minimal caregiver assistance to stand, balance and sit with the rolling walker.

An OT who worked with the beneficiary noted that the rolling walker "met prior level of functioning" for the beneficiary.

NHIC said the claim was denied because it was missing documentation proving that the beneficiary's mobility limitation could not be resolved with an appropriately fitted cane or walker. The claim also lacked documentation that the beneficiary could safely self propel the wheelchair and had caregiver assistance available to help with the wheelchair.

About the Author

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

Mobility Management Podcast