Manual Wheelchairs Quarterly Results of TPE Review - JD DME
Manual Wheelchairs Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes K0001 and K0003. The quarterly edit effectiveness results from July 2023 - September 2023 are as follows:
Based on dollars, the overall claim potential improper payment rate is 45%.
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 Criterion D - use of the manual wheelchair will significantly improve the beneficiary’s ability to participate in mobility related activities of daily living (MRADLs) and the beneficiary will use it on a regular basis in the home.
- Documentation does not demonstrate Criterion A - the beneficiary has a mobility limitation which significantly impairs their ability to participate in mobility related activities of daily living (MRADLs) within their home.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- 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 does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
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.