NHIC Reports Q3 K0823 Review Results

NHIC Corp. has released the results of a widespread prepayment review for Medicare consumer power chair claims processed in the third quarter of 2013.

The review is for Group 2 power wheelchairs in the K0823 HCPCS code, defined as having captain's-style seating and a user weight capacity up to and including 300 lbs.

For the July 1-Sept. 30 review period, NHIC, the Jurisdiction A DME MAC, said it examined 333 claims submitted by 132 different suppliers, who were issued Additional Documentation Requests (ADR).

For 79 of the claims, NHIC said it did not receive the required additional documentation.

For the 254 claims for which suppliers did provide additional documentation, NHIC said 98 claims were allowed, and 156 claims were denied.

"The total denied allowance amount - dollar amount of allowable charges for services determined to be billed in error - divided by the total allowance amount of services medically reviewed resulted in an overall charge denial rate of 52.8 percent," NHIC said in a Dec. 27 bulletin.

The 52.8-percent charge denial rate was a sharp decline from previous quarters' denial rates. The second-quarter 2013 charge denial rate was 82.8 percent; the rate for the first quarter of 2013 was 86.6 percent.

NHIC said the most common reason for denials was one or more issues with the face-to-face examination. That problem was present in 56.3 percent of claims that were denied.

Specific face-to-face exam problems included a failure to demonstrate medical necessity for the power chair (e.g., documentation did not rule out lesser types of mobility equipment, such as a cane, walker or scooter) and missing documentation, including missing physician signatures, signature dates or date stamps.

The second-most commonly seen errors involved issues with the Licensed Certified Medical Professional (LCMP) examination (e.g., the LCMP exam was missing the physician's agreement or disagreement with the OT or PT evaluation). Detailed product description errors were seen in 20.1 percent of denied claims, while 19.3 percent of denied claims had seven-element order problems, and 13.4 percent of denied claims had problems with home assessments.

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

About the Author

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

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