Terrible Results for Group 2 Power Wheelchairs – Audits Continue
Jurisdiction D has just released the results of its prepayment review of HCPCS K0823 (group 2 standard power wheelchairs with a capacity of up to 300lbs) - a review that is currently ongoing in Jurisdiction A.
According to the release, a total of 117 claims were reviewed for documentation requirements. Of these, 114 claims were denied. That’s over a 97% error rate! Of the 114 denied claims, almost 80% of denials were due to lack of medical necessity.
And while Jurisdiction A’s results are a little better, they’re still high enough to warrant a continuation of their prepayment review for K0823. From April - June of 2009, the NHIC reviewed 510 claims. Of these, 362 were denied, resulting in a 71% error rate. Of the 362 denied claims, 50% of denials were due to lack of medical necessity and another 39.5% were denied due to supplier generated, pre-printed forms (i.e. partially completed 7 element orders, supplier created mobility evaluation forms, and supplier formatted questionnaires used to document a face-to-face visit).
PMD Billing Reminders
Please remember that supplier generated forms are not substitutes for required medical documentation. They will not be considered in an audit, even if the physician completes and signs the forms. The best thing you can do is to educate your physician on the specific information that must be documented in the patient’s records to prove medical necessity.
Also, remember that when billing for any power mobility device (PMD) you must receive the written order within 45-days of a patient’s face-to-face examination. Written orders must be obtained prior to delivery and must include the following 7 elements:
- Beneficiary’s name.
- Description of the item that is ordered.
- Date of completion of the face-to-face examination.
- Pertinent diagnoses/conditions that relate to the need for the item.
- Length of need.
- Physician’s signature.
- Date of physician signature.
While you may create a form for the physician to fill out using the above 7 elements, you may NOT pre-populate any of the information. Also, forms must NOT hint at or “lead” the physician as to the type of equipment to be ordered. For example, a form that includes check boxes for various types of PMDs would not be acceptable.
When filling out a written order, the item description under number 2 does not have to be detailed. Physicians may use general descriptions, such as “power operated vehicle” or “power mobility device.”
And finally, when writing your detailed product descriptions you must include the following:
- The HCPCS code being billed.
- A narrative description of the HCPCS code.
- The manufacturer’s name and model name/number of the part.
- Medicare’s allowable payment.
Recently, DME MAC A released a clarification regarding the narrative description requirement. Per the release, the narrative does not have to include the entire description for each HCPCS code. However, it must be detailed enough to distinguish the item being billed from other similar items. This change will be included in a future LCD revision.
As a reminder, detailed product descriptions must be signed and dated by a patient’s physician prior to delivery of a power wheelchair (PWC) or power operated vehicle (POV). A date stamp or equivalent must be used to document receipt date, and the document must be available on request.
Tags: CERT Audits, DME MAC Audits, Group 2 Power Wheelchairs, Wheelchair Audits