TriCenturion Expands K0823 Probe; No Easy Button Here
COLUMBIA, S.C.--TriCenturion announced last week that it will continue a widespread pre-payment review of K0823 power wheelchairs after a probe review showed sky-high denial rates of 87.51 percent for Jurisdiction A and 93.36 percent for Jurisdiction B. (See HomeCare Monday, June 11.)

The Jurisdiction A/B DME program safeguard contractor said its pre-payment review for the code--Group 2 standard captain's chair with patient weight capacity up to and including 300 pounds--will continue in both regions.

"What this means is that the small sample size from the widespread probe will be increased to encompass virtually all claims for K0823 in Jurisdictions A and B," said Tim Pederson, CEO of WestMed Rehab, Rapid City, S.D., and chair of the American Association for Homecare's Rehab and Assistive Technology Council.

In a bulletin posted on its Web site Sept. 17, a chart comparing medical review determinations in TriCenturion's pre-payment probe showed that more than 60 percent of the claims in Jurisdiction A and more than half in Jurisdiction B were denied as "non-covered." More than 30 percent of claims in Jurisdiction B and more than 10 percent in Jurisdiction A were denied as "not medically necessary."

A list of reasons TriCenturion gave for denials included physician orders on which the date of the face-to-face evaluation was not documented or there was no date stamp to verify the supplier's receipt within 45 days. Other reasons included that functional limitations were not addressed in the evaluation, that letters of attestation were submitted without supporting information from the medical record and that some suppliers created mobility evaluation forms as a substitute for information from the medical record.

Issued last year, CMS' new power mobility rule replaced the power mobility CMN with a face-to-face exam and a doctor's prescription. But under new documentation requirements, providers are responsible for gathering patient records that prove medical necessity for the equipment.

Seth Johnson, director of government affairs for Pride Mobility Products, Exeter, Pa., said the probe "speaks volumes about the need for the policies and procedures currently in the interim final rule to be reexamined. I think it also clearly shows the need for CMS to do some extensive education with providers and, even more importantly, with the physicians. Clearly, the documentation expectations by the Medicare contractors are not clear to anyone when you have denial rates in the 90-percentile range.

"The biggest complaint that we hear from providers is the difficulty that they have in getting this information from physicians," Johnson continued. "Physicians just are not in the practice of providing so much information for other items they prescribe."

Eric Sokol, executive director of the Power Mobility Coalition, said the Washington-based organization has "real concerns" with CMS' lack of analysis of the paperwork burden on providers in gathering PWC documentation. According to Sokol, while CMS said there would be no tangible difference in the burden on suppliers under the new rule as in obtaining a CMN, he said, "that is certainly not the case."

The coalition has submitted comments on the matter to the Office of Management and Budget, which is currently reviewing the paperwork burden, Sokol said.

"Right now, it's just a documentation requirement that's amorphous, that's never-ending as far as what CMS wants, and it creates a claims processing system where CMS holds all the cards and all the claim reviews are subjective," Sokol said. He added that he hopes CMS will work with the industry to come up with a tool where a physician could complete all necessary steps, then the provider could submit that along with any supporting documentation and have "a reasonable expectation of payment."

Pederson said the degree to which physicians, therapists and providers are confused about PWC documentation requirements should be more certain after providers complete the appeals process on claims denied in the preliminary probe. "Certainly these providers will appeal the findings of the probe," Pederson said. "It will be interesting to follow the group of claims through the appeal process to find out what the final percentage of denials ends up to be."

In addition, Pederson said, "we need to know what the final medical necessity denial rate is versus [the] documentation error rate." That data, he said, "will tell us what the shortcomings are of the educational efforts of CMS, manufacturers, trade associations, group purchasing organizations and providers themselves ...

"We need to keep in mind that the overhaul of the power mobility device policy was sweeping and comprehensive," Pederson continued. "It is evident that at least some of the providers in our industry did not adequately prepare for providing power wheelchairs under our new reality ... Personally," he added, "I think we are seeing the results of what happens to those providers who respond by wishing for the 'easy button' instead of facing our current reality and changing the way they do business."

Pederson said the industry is seeing PMD utilization down "around 20 percent from two years ago. This is a direct result of the new PMD policies and their related documentation requirements. We can't wish this situation away. We need to move forward and do what is asked of us or we will not get paid or be allowed to keep our payments after an audit."

TriCenturion said providers whose claims are selected for review will receive an Additional Documentation Request letter "asking for specific information to determine if the item billed complies with the existing reasonable and necessary criteria." Failure to supply the information within 30 days of the request will result in denial of the claim, the PSC said.

View the TriCenturion bulletin in full.