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 July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 24%.
Top Medical Necessity Denial Reasons
- 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
- 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.
- Claims history indicates same or similar durable medical equipment within the last five years. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50.1.
- Documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 & Standard Documentation Requirements A55426.
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.
