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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 October 1 and December 31, 2023. The error rate for this quarter is 41.43%. 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. 21.32%
2. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212External PDF 11.34%
3. Neither the medical records nor supplier documentation included a home assessment. 9.85%
4. When a home assessment is based on indirectly obtained information, the supplier must verify at the time of delivery that the home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair being provided. Documentation did not include proof of this verification. 8.64%
5. 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. 6.21%
6. The medical record documentation does not indicate the beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. 6.07%
7. The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website 4.59%
8. The home assessment did not address the physical layout of the home, surfaces to be traversed and/or obstacles. 4.59%
9. The supply or accessory is denied as the base equipment is denied. Refer to Manual Wheelchair Bases – Policy Article (A52497)External Website and Manual Wheelchair Bases (L33788)External Website 4.59%
10. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 3.91%

*The total percentage will be greater than 100% because some claims were 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 represent an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: February 2, 2024

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