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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 32.05%. 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. 31.51%
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. 13.21%
3. The medical record documentation does not support that use of a manual wheelchair will significantly improve the beneficiary's ability to take part in mobility related activities of daily living and the beneficiary will be using it on a regular basis in the home. 9.25%
4. 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. 6.23%
5. Neither the medical records nor supplier documentation included a home assessment. 6.04%
6. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. 5.85%
7. The documentation does not have a valid order. 3.96%
8. The home assessment did not address the physical layout of the home, surfaces, or obstacles. 3.96%
9. The records do not document that the beneficiary's condition requires a K0004 (high strength lightweight) wheelchair either because he/she is unable to self-propel a standard (K0001-K0002) or lightweight (K0003) wheelchair or requires a seat width, depth or height that cannot be accommodated in a K0001 - K0003 and spends at least 2 hours per day in a wheelchair. 2.26%
10. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 2.08%

*The total percentage will be greater than 100% because some claims 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 5, 2024

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