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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 between January 1 and March 31, 2024. The error rate for this quarter is 35.24%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 17.21%
2. The standard written order (SWO) is missing a description of the item. 11.48%
3. 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. 11.48%
4. When a home assessment is based on indirectly obtained information, the supplier must verify at the time of delivery that the home has adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair being provided. Documentation did not include proof of this verification. 10.66%
5. Neither the medical records nor supplier documentation included a home assessment. 9.02%
6. The documentation does not have a valid SWO. 7.38%
7. The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. 4.92%
8. We did not receive any medical record documentation. 4.10%
9. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 3.28%
10. The records do not document that the beneficiary's condition requires a K0004 (high strength lightweight) wheelchair either because they are 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 two hours per day in a wheelchair. 3.28%

*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: May 21, 2024

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