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April 1, 2021

Widespread Post-Pay, Service-Specific Review Announcement – HCPCS Codes K0001-K0004

CGS' Medical Review staff will be conducting a complex post-pay, service-specific medical review of HCPCS codes K0001 through K0004 (Manual Wheelchairs). This review will be conducted because data analysis revealed that Jurisdiction B's allowed dollars for these codes were above the expected amounts. Additionally, the manual wheelchair policy group continues to rank high in Comprehensive Error Rate Testing (CERT) errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in federal law at SSA 1833 (e) and in federal regulation at 42 CFR 424.5(a)(6). Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Five Element Order for the manual wheelchair obtained prior to delivery for items under the Affordable Care Act (ACA) 6407
  2. Detailed written order for any items not under the ACA 6407
  3. Itemized proof of delivery documentation for the item(s) provided
  4. For replacement chairs: Claim history shows that the previous equipment has reached its reasonable useful lifetime (replacement is 5 years or more after the date of delivery for previous equipment); or records verify that the previous equipment has been lost, stolen, or irreparably damaged in a specific incident
  5. Medical records that support that the beneficiary meets the general manual wheelchair coverage criteria listed in the Manual Wheelchair Bases Local Coverage Determination (LCD)
  6. Medical records that support that the beneficiary meets the HCPCS code-specific coverage criteria listed in the Manual Wheelchair LCD
  7. Documentation of a home assessment, per LCD and policy article guidelines, that verifies the beneficiary's home can accommodate the wheelchair
  8. Any other pertinent records
  9. Advance Beneficiary Notice (ABN) on file should be submitted with other requested documentation


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