RemitDATA reported a 16.8 percent denial rate for its customers who submitted K0823 claims processed during the second quarter this year. That's high enough, but in a recent prepayment review of 1,000 claims for HCPCS K0823 (power wheelchair, Group 2 standard, captain's chair, capacity up to and including 300 pounds), in Jurisdiction A, NHIC found a 76.3 percent claim denial rate.
If your company becomes subject to this or another jurisdiction's prepayment review, remember that you will receive an Additional Documentation Request, or ADR, asking for specific information to determine whether the item billed complies with the existing reasonable and necessary criteria. Failure to supply the information within 30 days of the date on the letter may result in claim denial.
Based on the review of K0823 documentation received by NHIC, the following were among the primary reasons for denial. (See the NHIC website at www.medicarenhic.com/dme for the full explanation.)
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Incomplete documentation (78.9 percent):
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One or more document(s) not provided; no seven-element order/prescription; no detail product description; no physician face-to-face examination/mobility evaluation; no home evaluation/assessment; no LCMP; no attestation of financial relationship.
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Seven-element order/prescription missing one or more elements (date of face-to-face, length of need, description of item, etc.).
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Detail product description not signed or signature and/or date illegible, allowance amounts not included, dated prior to completion of face-to-face/mobility evaluation.
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Determined to be medically unnecessary (16.1 percent):
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Face-to-face; not a physical exam; did not address mobility issue; only attesting to agree with PT evaluation.
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Upper extremity/lower extremity issues not addressed.
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Insufficient documentation submitted to establish medical necessity for PMD.
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Additional reasons for denial (5.1 percent) included duplicate claims, late claim filing. wheelchair returned to supplier and claim billed in error.
To ensure compliance, perform your own audit of your K0823 claims. Get back to the basics and review the information in your files to make sure it matches the LCD. Taking the extra time and training your team on these requirements could save you from Medicare monetary take-backs resulting from claims being denied upon additional review.
Based on analysis of 5,217,235 Medicare claims processed for RemitDATA customers during the second quarter of 2010. Source: RemitDATA, 866/885-2974, www.remitdata.com
Read more Working Down Denials columns.
Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.
