Skip to Main Content

Print | Bookmark | Email | Font Size: + |

Manual Wheelchairs Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for manual wheelchairs HCPCS codes K0001-K0004 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 44.13%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical records do not document that the beneficiary either has sufficient upper extremity function and other physical and mental capabilities needed to, in the home during a typical day, safely self-propel the manual wheelchair that is provided or has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 20.61%
2. The records do not document that the beneficiary's condition requires a K0003 due to the inability to self-propel a standard wheelchair in the home and that the beneficiary can and does self-propel a lightweight wheelchair. 12.98%
3. The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9External PDF 8.40%
4. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212External PDF 8.40%
5. The home assessment did not address the physical layout of the home, surfaces to be traversed and/or obstacles. 7.25%
6. The medical record documentation does not support that use of a manual wheelchair will significantly improve the beneficiary's ability to participate in mobility related activities of daily living and the beneficiary will be using it on a regular basis in the home. 6.49%
7. The medical record documentation does not indicate the beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. 5.73%
8. Neither the medical records nor supplier documentation included a home assessment. 4.96%
9. When a home assessment is based on indirectly obtained information, the supplier must verify at the time of delivery that the home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair being provided. Documentation did not include proof of this verification. 4.20%
10. The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2External PDF and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website 3.44%

*The total percentage will be greater than 100% because some claims were denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: February 2, 2024

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved