National Government Services (NGS), the Jurisdiction B DME MAC, reported that in the first three months of this year, there was a 70-percent claim error rate in prepayment reviews for K0823-coded power wheelchairs.
The prepayment reviews covered Group 2 standard power wheelchairs with captain’s seating and a weight capacity up to and including 300 lbs., plus related accessories.
From Jan. 1 through March 31, 2011, NGS’s medical review department reviewed 63 claims that were developed for additional documentation, according to a bulletin sent out in April by NGS.
Of the 63 claims, 44 were denied.
NGS listed two major reasons for the denials:
• Failure of the provider to respond within 30 days to the call for additional documentation. NGS said 18 percent of claims were denied for this reason.
• Failure to submit medical records, or the medical records provided did not establish the beneficiary’s medical necessity. NGS did not indicate how many of the 44 claims were denied because of insufficient or missing medical documentation.
NGS indicated that the widespread prepayment medical review continues, and that claims were examined “to assure that all coverage criteria and other documentation requirements were met.”
NGS also recommended that suppliers review and learn “documentation requirements and utilization parameters as outlined in the power mobility devices local coverage determination (LCD L27239) and policy article (PA A47122) online at ngsmedicare.com.
