NHIC Corp., the Jurisdiction A DME MAC, has reported an overall Charge Denial Rate of 55.9 percent for its quarter two widespread prepayment review for Group 2 standard power chair claims.
The prepayment review for HCPCS code K0823 will continue based on those quarter two results, NHIC said in a bulletin issued last week. The 55.9-percent Charge Denial Rate was higher than the rates reported for the first quarter of this year (52 percent) and the last quarter of 2010 (52.4 percent), but is still significantly lower than the Charge Denial Rate for a year ago at this time (75.3 percent), when the review began.
For quarter two, NHIC said 241 suppliers filed 868 claims involving the K0823 code. At that point, suppliers were instructed to send additional documentation, but NHIC said it didn’t receive the requested documentation for 15 percent of those claims.
Suppliers did forward additional documentation for 738 claims, and of those, 418 claims were denied.
NHIC said 57 percent of the claims were denied due to “insufficient clinical documentation to support medical necessity.” Examples of insufficient documentation included failure of the ordering clinician’s face-to-face power mobility exam “to substantiate that a patient is prevented from accomplishing mobility-related activities of daily living (MRADLs) due to mobility deficits.” Documentation may also have failed to explain why a beneficiary would be at risk while trying to perform MRADLs without the use of a power chair.
Face-to-face exam documentation may also have failed to include “a comprehensive physical exam that provided objective measurements to provide a clear picture of the patient’s specific mobility limitations, i.e., upper- and lower-body strength, range of motion, coordination, pain levels, physical deformities and physical endurance.”
NHIC’s bulletin said 8.1 percent of denied claims were missing some of the elements required in the “7-element order,” while 3 percent of the denied claims didn’t contain a 7-element order at all. Another 10.5 percent of denied claims “had 7-element orders that did not include confirmation the supplier received a copy within 45 days after the completion of (the) face-to-face exam, as verified by a supplier date stamp or equivalent.”
Lack of home assessment prior to power chair delivery was noted in 6 percent of denied claims, while 2.6 percent of denied claims were missing detailed product descriptions, and 6.5 percent of denied claims “did not note that the supplier received, signed and dated the detailed product description prior to the delivery of the device.”
In addition to stating that it would continue to perform K0823 prepayment reviews, NHIC warned suppliers that repeated failures to respond to requests for additional documentation for such claims “could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.”
