The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes K0001 & K0003. The quarterly edit effectiveness results from January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 52%.

Top Medical Necessity Denial Reasons

• The documentation does not demonstrate Criterion F - the beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
• The documentation does not demonstrate Criterion G - the beneficiary has a caregiver who is available, willing and able to provide assistance with the wheelchair.
• The 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.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• 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 210-212.
• The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 & 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.