NHIC Corp., the Jurisdiction A DME MAC, continues to release examples of Medicare claims that were reviewed by the Comprehensive Error Rate Testing (CERT) contractor and denied.
The latest examples, NHIC said in a March news announcement, were errors reported in December 2011.
For power mobility devices (PMD), the first example was for a Group 2 standard power chair with captain’s seat.
NHIC says the supplier submitting the claim included a detailed product description; a seven-element order; patient’s body weight (175 lbs.); progress notes for a “mobility exam”; the date of delivery; an MRI report; a home assessment report; and additional progress notes that discussed a “shoulder injection.”
NHIC says the CERT contractor rejected the claim because of missing documentation – namely, “Treating physician’s face-to-face evaluation which supports a sufficiently detailed evaluation of the beneficiary’s mobility limitations affecting participation in mobility-related activities of daily living, which are not able to be resolved by use of an appropriately fitted cane, walker or manual wheelchair, and documentation to support the beneficiary does not have sufficient upper-extremity function to self propel a manual wheelchair and is unable to use a POV.”
The second example of a PMD claim that was denied, NHIC said, was for a Group 2 portable power chair with captain’s seat and a pair of elevating legrests.
The supplier included a detailed product description; a seven-element order; a home evaluation; proof of delivery; and a progress note for a power wheelchair evaluation.
The progress note, NHIC reported, stated the beneficiary “gets only limited help with cane/walker” and “cannot use the walker outside.” The progress note added the patient “is severely limited, difficult to get around to necessary providers.”
NHIC said the progress note did not include “a musculoskeletal exam documenting arm and leg strength or range of motion, or a neuro exam documenting gait, balance and coordination.”
NHIC added that a comprehensive face-to-face mobility examination was also missing, and that the examination should have included “progression of ambulation difficulty over time and why a cane or walker cannot sufficiently resolve mobility issues, or why beneficiary cannot safely use an optimally configured manual wheelchair.”
The CERT contractor also noted, “The beneficiary face-to-face exam does not make it clear why the beneficiary’s mobility needs progressed to the need for the power wheelchair… The exam did not do objective joint exam or upper-extremity exam to support the beneficiary’s inability to self propel, nor is there objective measure of pulmonary function and oxygen saturation to support the assertion that the beneficiary’s COPD contributes to the need for a power wheelchair.”
NHIC said the monthly examples of denied claims represent the “top” errors discovered by the CERT contractor.
“As you review this information,” NHIC said, “consider the missing documentation that caused the error…NHIC Corp. DME MAC A expects these examples will assist suppliers in understanding the CERT review process, and to become familiar with the type of medical records requested.”
