Manual Wheelchair 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 code(s) K0001 and K0003 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 – September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 15%.

Top Medical Necessity Denial Reasons

  • The documentation does not demonstrate the beneficiary cannot self-propel in a standard wheelchair in the home.
  • The documentation does not demonstrate the beneficiary can and does self-propel in a lightweight wheelchair.
  • The 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.

Top Technical Denial Reasons

  • Related item denied due to invalid Standard Written Order (SWO).
  • The item was provided prior to an inpatient hospital admission or Part A covered skilled nursing facility stay and its use began during the stay.
  • 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.

Last Updated Oct 28 , 2025