The prepayment review for standard power wheelchair claims continues in DME MAC Jurisdiction A, due to the latest quarterly results, NHIC Corp. has announced.
In a statement last week, NHIC said it found a 62.6-percent charge denial rate among claims for power wheelchairs in the K0823 code – defined as Group 2 standard power chairs with captain’s seating and with weight capacities up to and including 300 lbs.
The latest findings are for claims with paid dates primarily in the October through December 2010 time period.
NHIC says it reviewed 779 claims that were submitted by 251 equipment suppliers. As part of its review, NHIC requested additional documentation for those 779 claims.
NHIC says it did not receive the additional documentation it requested in 27 percent of the claims it sought to review.
For the 566 claims in which suppliers did submit additional documentation, NHIC said, “221 claims were allowed, and 345 were denied.”
Among the most common reasons for denials, NHIC listed the following:
No evidence of home assessments being completed prior to or upon delivery of the power chair (10 percent of denials).
No valid delivery tickets (12 percent of denials).
Seven-element order was incomplete or missing (12 percent).
Claims lacked clinical documentation to justify medical necessity (60 percent).
In the documentation category, NHIC cited examples of the clinician’s face-to-face mobility exam failing to demonstrate that mobility impairments prevented the patient from performing mobility-related activities of daily living; of face-to-face exams failing to include a comprehensive medical examination that details the patient’s specific mobility impairments, such as lack of upper- or lower-body strength or range of motion; and failure to document and detail why a lower level of mobility equipment, such as a walker or manual chair, could have sufficiently met the patient’s needs.
Last week’s NHIC bulletin listed three actual examples of denied claims and detailed why each had been denied.
“Based on the results of this prepayment review, DME MAC A will continue to review claims billed with HCPCS (code) K0823,” the NHIC statement said.
NHIC added, “Suppliers are reminded that repeated failure to respond to ADR (additional documentation requests) could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.”
