National Government Services (NGS), the Jurisdiction B DME MAC, has released its widespread prepayment review findings for power wheelchair claims examined in the third quarter.
The power chairs being reviewed are HCPCS coded K0823, defined as group 2 standard power wheelchairs with captain’s seating and patient weight capacities up to and including 300 lbs.
From July 1 through Sept. 30, 2012, NGS reviewed 333 claims and requested that providers send additional documentation. Of those claims, NGS paid 56 in full. The remaining claims were completely or partially denied, which resulted in a claims error rate of 86 percent.
NGS said the most common reason for a denial was that “requested medical records did not establish medical necessity.” That included providers’ failure to prove that an optimally configured manual chair would not meet the beneficiary’s needs, or that basic local coverage criteria C were not met. The lack of proven medical necessity occurred in 24 percent of denied claims, NGS reported.
Other claims were denied because medical records did not adequately prove that more basic equipment such as a cane or walker would not suffice, or that the required face-to-face examination with a physician occurred.
