Manual Wheelchair Quarterly Results of Targeted Probe and Educate Review - JA DME
Manual Wheelchair Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) K0001 and K0003. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 7%.
Top Medical Necessity Denial Reasons
- Documentation does not demonstrate Criterion B – the beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
- Documentation does not demonstrate the beneficiary cannot self-propel in a standard wheelchair in the home.
- Documentation does not demonstrate the beneficiary can and does self-propel in a lightweight wheelchair.
Top Technical Denial Reasons
- Treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
- 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 210-212.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Manual Wheelchairs webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.
See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.
