NHIC Corp., the Jurisdiction A DME MAC, has released the 2008 quarter 4 and 2009 quarter 1 findings of its ongoing K0823 pre-payment probe.
The K0823 HCPCS code represents Group 2, standard power chairs with captain’s seating and with a user weight capacity of up to and including 300 lbs.
The 2008 Q4 review studied 105 claims submitted by 30 suppliers, NHIC reported. Of that total, 34 claims were allowed, while 71 were denied — a denial rate of 67.62 percent.
The 2009 Q1 results showed that 348 claims from 125 suppliers were studied, with 129 claims being paid and 219 denied. The denial rate was 62.78 percent.
NHIC said the following reasons accounted for most of the denials:
• Documentation did not provide enough details when describing the beneficiary’s limitations in performing mobility-related activities of daily living (MRADLs). NHIC noted, “Documentation should identify specific limitations and clearly indicate what they can and cannot complete in terms of MRADLs.”
• Documentation did not go into sufficient detail when explaining why the beneficiary needed a power chair instead of “an optimally configured manual wheelchair in the home in order to perform his/her MRADLs during a typical day.” NHIC says documentation should include strength levels and degrees of range of motion of the beneficiary’s upper and lower extremities; endurance levels; pain ratings; and how MRADLs are impacted by those pain ratings.
• Face-to-face mobility exam forms didn’t properly record a complete medical examination or did not provide enough detailed information to prove medical necessity for the power chair.
• Face-to-face exam forms and medical necessity documentation lacked detail, or information on the forms was not consistent throughout. Information on some forms contradicted other information on the same forms.
• Sequences of events were out of order or forms lacked proper date-related information, such as the seven-element order/prescription being signed by the physician, but not dated.
NHIC further announced that because the error rate “must reflect a reduction of 70 percent or more,” the pre-payment review of K0823 power chairs will continue. As part of the review, K0823 claims are being randomly selected, and the involved suppliers are sent an automated development response letter that requests additional documentation.
That documentation is then reviewed by a clinical staff to judge its compliance with Medicare rules and regulations.