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December 12, 2013

Status Report for Quarter 3 - 2013 HCPCS Code K0823 Service-Specific Prepayment Review

The Medical Review Department of CGS, the Jurisdiction C DME MAC, began a service-specific prepayment review of HCPCS code K0823 (Group 2 Standard Power Wheelchair with Captains Chair) claims in July 2009. This review is the result of data demonstrating a high claims payment error rate for this product category.

A summary report for claims reviewed between July 1, 2013 and September 30, 2013 follows. Please note that this information does not reflect review data from the Power Mobility Prior Authorization Demonstration Project.

  Current Quarter Previous Quarter
Denial Rate 54% 72%
Allowed Dollars Error Rate 54% 69%
error rate trend

Non-response Rate to Additional Documentation Requests –9%

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim included:

  • The face-to-face evaluation did not provide a measurable assessment of upper extremity strength and function, so the reviewer could not rule out that the beneficiary was unable to use an optimally configured manual wheelchair.
  • The medical records did not explain how the use of power mobility would significantly improve the beneficiary's ability to participate in MRADLs in the home.
  • The face-to-face evaluation provided vague, subjective statements concerning the beneficiary's functional abilities, i.e., a generic restatement of verbiage in the LCD rather than an individualized physical assessment.
  • Assessments regarding the beneficiary's functional level did not support that the mobility limitation could not be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
  • The seven-element written order was missing the date of the face-to-face examination or the date provided was incorrect.
  • The supplier completed the DPD prior to receiving a signed and dated copy of the seven-element order from the physician. By policy, the DPD cannot be completed by the supplier until after the supplier has received the 7EO from the physician.
  • The seven-element written order was missing a date stamp or equivalent showing the date the supplier received it from the physician.
  • The Detailed Product Description was missing a date stamp or equivalent indicating when the supplier received it from the physician.
  • The ordering physician did not complete all elements of the seven-element order.
  • The Face-to-Face Evaluation was missing a date stamp or equivalent indicating when the supplier received it from the physician.

Case Study

M.W. – 58 year old male
Diagnoses – Left below knee amputation, cerebrovascular accident (CVA) with right hemiparesis, low back pain due to osteoarthritis

The medical records included the following documents:

  • Mobility evaluation conducted by a physical therapist – Dated 07/31/2013. The ordering physician signed this evaluation on 10/03/2013 and stated that he agreed with the findings in the evaluation.
  • Notes from a face-to-face evaluation performed by the ordering physician on 09/26/2013. The physician indicated that the purpose of the visit was for a power mobility (PMD) evaluation.

The face-to-face (F2F) date listed on the seven-element order (7EO) was 10/03/2013. Based on the above information, is this the correct F2F date?

Answer: No, 10/03/2013 was not the correct date to put on the 7EO. The date that the physician signs/concurs with an LCMP evaluation can only be used as the F2F date IF the ordering physician does not see the beneficiary after the LCMP visit. If the ordering physician either sees the beneficiary for the initial PMD evaluation visit after the LCMP evaluation or for a follow-up visit after the LCMP evaluation, then the date of the physician visit is the correct F2F date. This applies even if the physician does not sign/concur with the LCMP evaluation until after the date of the physician visit.

The correct F2F date for the above scenario is 09/26/2013 because there was a F2F encounter between the physician and beneficiary AFTER the LCMP visit. The only physician visit related to a PMD evaluation would have to have occurred on or before 07/31 for 10/03 to be the correct F2F date.

Please refer to the online article, "Face-to-Face Examination Date on 7-Element Order for Power Mobility Devices Scenarios", for additional information concerning this requirement.

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