In a recent prepayment review of 1,000 claims for HCPCS K0823 in Jurisdiction A, NHIC found a 76.3 percent claim denial rate.
by Sarah Hanna

RemitDATA reported a 16.8 percent denial rate for its customers
who submitted K0823 claims processed during the second quarter this
year. That's high enough, but in a recent prepayment review of
1,000 claims for HCPCS K0823 (power wheelchair, Group 2 standard,
captain's chair, capacity up to and including 300 pounds), in
Jurisdiction A, NHIC found a 76.3 percent claim denial rate.

If your company becomes subject to this or another
jurisdiction's prepayment review, remember that you will receive an
Additional Documentation Request, or ADR, asking for specific
information to determine whether the item billed complies with the
existing reasonable and necessary criteria. Failure to supply the
information within 30 days of the date on the letter may result in
claim denial.

Based on the review of K0823 documentation received by NHIC, the
following were among the primary reasons for denial. (See the NHIC
website at for the full

  • Incomplete documentation (78.9 percent):

    • One or more document(s) not provided; no seven-element
      order/prescription; no detail product description; no physician
      face-to-face examination/mobility evaluation; no home
      evaluation/assessment; no LCMP; no attestation of financial

    • Seven-element order/prescription missing one or more elements
      (date of face-to-face, length of need, description of item,

    • Detail product description not signed or signature and/or date
      illegible, allowance amounts not included, dated prior to
      completion of face-to-face/mobility evaluation.

  • Determined to be medically unnecessary (16.1

    • Face-to-face; not a physical exam; did not address mobility
      issue; only attesting to agree with PT evaluation.

    • Upper extremity/lower extremity issues not addressed.

    • Insufficient documentation submitted to establish medical
      necessity for PMD.

  • Additional reasons for denial (5.1 percent) included
    duplicate claims, late claim filing. wheelchair returned to
    supplier and claim billed in error.

To ensure compliance, perform your own audit of your K0823
claims. Get back to the basics and review the information in your
files to make sure it matches the LCD. Taking the extra time and
training your team on these requirements could save you from
Medicare monetary take-backs resulting from claims being denied
upon additional review.

Based on analysis of 5,217,235 Medicare claims processed for
RemitDATA customers during the second quarter of 2010. Source:
RemitDATA, 866/885-2974,

Read more Working Down Denials

Sarah Hanna is a reimbursement consultant and vice president
of ECS Billing
& Consulting
, Tiffin, Ohio, and specializes in proper
billing protocols, Medicare coverage guidelines and billing office
procedures. You can reach her at 419/448-5332 or