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Manual Wheelchairs Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for manual wheelchairs HCPCS codes K0001-K0004 reviewed July 1 – September 30, 2024. The error rate for this quarter is 34.41%. 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. 28.99%
2. The medical record documentation does not show the beneficiary's mobility limitation cannot be sufficiently and safely resolved using an appropriately fitted cane or walker. 11.11%
3. Neither the medical records nor supplier documentation included a home assessment. 8.70%
4. 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. 8.21%
5. The order is missing a description of the item. 5.31%
6. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 4.83%
7. Medical records do not support that the beneficiary requires a lower seat height (17" to 18") because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion. 4.83%
8. 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. 4.83%
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. 4.35%
10. The supply or accessory is denied as the base equipment is denied. 4.35%

*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 be an overall error rate for the HCPCS code or policy under medical record review.

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Updated: November 1, 2024

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