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NHIC Review Provides Clues to DME Claims Denial

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  • February 15, 2010
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Are your durable medical equipment (DME) claims for power wheelchairs being denied? You’re not alone. In a recent NHIC, Corp. quarterly review, 70 percent of claims for HCPCS Level II code K0823 Power wheelchair, group 2 standard, captain’s chair, patient weight capacity up to and including 300 pounds were denied.
Prepayment complex medical review of 80 claims submitted between Oct. 1, 2009 and Dec. 1, 2009 by 59 suppliers resulted in 24 allowed claims and 66 denied, reports the DME Medicare Administrative Contractor (MAC) for northeastern states in jurisdiction A. The total denied allowance amount divided by the total allowance amount of services medically reviewed resulted in an average charge denial rate of 72.086 percent.

Top Reasons for Claims Denial

According to the review, the primary reasons for denial were medical necessity (46.4 percent), or lack thereof, incomplete supplier-generated pre-printed forms (16.1 percent), and inadequate documentation (33.9 percent).
Based on these findings, NHIC says it will continue to review claims billed with HCPCS Level II code K0823.

Best Ways to Prevent Claims Denial

NHIC’s Local Coverage Determination (LCD) for Power Mobility Devices (L21271) is a good place to start for coding and billing advice of K0823. One of the main reasons for claim denial in the NHIC quarterly review was the absence of a face-to-face seven-element examination. The LCD clearly identifies the seven required elements:

  1. Beneficiary’s name;
  2. Description of the item that is ordered;
  3. Date of the face-to-face examination;
  4. Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair;
  5. Length of need;
  6. Physician’s signature; and
  7. Date of physician signature.

Another top contender for denial is the inappropriate use of supplier-generated forms by physicians. As stated in the LCD, “Many suppliers have created forms which have not been approved by CMS which they send to physicians and ask them to complete. Even if the physician completes this type of form and puts it in his/her medical chart, this supplier-generated form is not a substitute for the comprehensive medical record.”
This brings us to the third reason so many claims for K0283 are being denied: incomplete documentation. As referenced in the Medicare Program Integrity Manual, Pub. 100-08, chapter 5.7 – Documentation in the Patient’s Medical Record, “… neither a physician’s order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).”
And last but not least, the LCD reminds us, “A date stamp or equivalent must be used to document receipt date.”
For further guidance, you may also find useful the NHIC educational articles “Power Mobility Devices Billing Reminder” and “Power Mobility Devices – 7-Element Order.”

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