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 2022 - September 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 35%.

Top Medical Necessity Denial Reasons

  • 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.
  • 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.

Top Technical Denial Reasons

  • 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.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section
  • The 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.

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 Wed, 02 Nov 2022 19:36:22 +0000