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.
Resources:
- Manual Wheelchair Bases Documentation Checklist

- Manual Wheelchair Bases – Policy Article (A52497)

- Manual Wheelchair Bases (L33788)

- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

- Supplier Manual Chapter 3 – Supplier Documentation

Updated: November 5, 2024

