The Jurisdiction B DME MAC denied 74 percent of Group 2 standard power wheelchair Medicare claims selected for widespread prepayment review in the third quarter of this year.
National Government Services (NGS) examined 163 claims from July 1 through Sept. 30 of this year and said 121 of those claims were denied.
NGS requested additional documentation for the K0823 claims, selected “to assure that all coverage criteria and other documentation requirements were met,” according to an announcement from NGS.
Among the reasons the claims were denied:
— No medical records submitted, or the medical records that were submitted did not establish medical necessity. This accounted for 33 percent of denials.
— Insufficient evidence that a physician face-to-face mobility examination was conducted.
— The seven-element order or the detailed product description was invalid or incomplete.
NGS is continuing its prepayment review, which is for Group 2 power chairs with captain’s-style seating and with a patient weight capacity up to and including 300 lbs.
So far in 2011, the prepayment review denial rate for standard Group 2 power chairs has been relatively consistent according to NGS reports.
For the second quarter of 2011, NGS reported a K0823 prepayment review denial rate of 77 percent (88 of 115 claims denied). For the first quarter of this year, NGS reported a 70-percent prepayment review denial rate (44 of 63 claims denied).
Failure of providers to send in sufficient additional documentation for claims selected for prepayment review was cited by NGS as a major reason for K0823 denials for all three quarters.
