Top Reasons for Non-Affirmative Condition of Payment Prior Authorization (K0856 and K0861) Decisions
Skip to main content
Corporate

TNCPE Logo


August 2, 2017 - Updated 07.03.18

Top Reasons for Non-Affirmative Condition of Payment Prior Authorization (K0856 and K0861) Decisions

The following are the top non-affirmative decision reasons for the Condition of Payment Prior Authorization (K0856 and K0861) for CGS DME MAC Jurisdictions B and C including information and resources to decrease the non-affirmative decisions.

7-Element Order and Face-to-Face

  • 7-element order did not include a valid face-to-face date or was dated prior to the completion of the face-to-face requirements.
    • For a Power Wheelchair (PWC ) to be covered the treating practitioner must conduct a face-to-face examination of the beneficiary before writing the order and the supplier must receive a written report of this examination within 45 days after completion of the face-to-face examination and prior to delivery of the device.
  • The supplier did not receive a valid copy of the 7-element order within 45 days after the completion of the face-to-face examination.
    • The supplier must receive a written report of this examination within 45 days after completion of the face-to-face examination and prior to delivery of the device.
  • 7-element order was not written by the same physician/practitioner who completed the face-to-face examination.
    • The practitioner who has conducted the face-to-face examination must write the 7-element order. It is a statutory requirement that all items of the 7-element order be entered specifically by and only by the practitioner who has conducted the face-to-face requirements. The supplier may provide a template order listing the seven required elements but is prohibited from completing any part of it.
  • The face-to-face examination was not signed; therefore the identity and credentials of the author cannot be authenticated.
    • For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author.
    • The method used shall be a handwritten or electronic signature. Additional information regarding signature requirements is located in the CMS Fact Sheet: Complying with Medicare Signature RequirementsExternal PDF.
    • A signature attestation may be submitted along with unsigned medical records to fulfill the signature requirements.
  • The documentation contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles.
    • Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, SMRC and ZPICs containing amendments, corrections or addenda must:
      • Clearly and permanently identify any amendment, correction or delayed entry as such, and
      • Clearly indicate the date and author of any amendment, correction or delayed entry, and
      • Clearly identify all original content, without deletion.

      Refer to the Medicare Program Integrity Manual 100-08 Chapter 3.3.2.5External PDF or Change Request 10120External PDF regarding addendums.

  • The documentation did not include verification that the supplier's Assistive Technology Professional (ATP) has a current Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certification or that they were employed by the supplier, and had direct in-person involvement in the selection of the power mobility device for this beneficiary.
    • The Power Mobility Device LCD requires that the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

      For additional information refer to the ATP Frequently Asked Questions at the following links:

  • The documentation did not indicate that the beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being used on the power mobility device, or that the beneficiary uses a ventilator which is mounted on the power mobility device.
    • POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002-E1012):
      • A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:
        1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and
        2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and
        3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
        4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
        5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
        6. The power seating system is needed to manage increased tone or spasticity.

        Or

      • For ventilators that are mounted on the wheelchair confirm all of the coverage criteria listed in the LCD Group 3 criteria IV(A) and IV(B) are met; and Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.
  • The documentation did not indicate the beneficiary's mobility limitations are due to a neurological condition, myopathy, or congenital skeletal deformity.
    • A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) is covered if:
      1. The Group 3 criteria IV(A) and IV(B) all of the coverage criteria (a)-(e) for a PWC are met; and the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity are met; and
      2. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.

Additional Resources:

Local Coverage Determination and Policy Articles

Medical Review Resources for Power Mobility Devices:

Medicare Minute™

Condition of Payment Prior Authorization:


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved