Wednesday, June 10, 2009

FARGO, N.D.--According to a notice from Noridian Administrative Services, the Jurisdiction D DME MAC has been monitoring claims for K0823 power wheelchairs, and the outcome on documentation for those claims isn’t so good.

As a result of the monitoring, NAS said it had “found the documentation submitted is insufficient to support even the basic coverage criteria for a power mobility device.”

According to the June 9 update, the PWC documentation lacks details in a number of areas, namely:
 
· Mobility-related activities of daily living (MRADLs) limitations are not provided in detail.
· Why a cane or walker is insufficient.  
· Whether the beneficiary does not have sufficient upper extremity function to self-propel a manual wheelchair in the home in order to perform his/her MRADLs during a typical day.
· Whether a walker or manual wheelchair has been tried, and the results of the trial.
· Why the beneficiary is unable to use a scooter.
 
In addition to addressing the MRADLs in detail, the DME MAC said medical documentation should include:
 
· Strength levels and degrees of range of motion of the beneficiary's upper and lower extremities;
· Coordination;
· Transferring abilities: self, assist of how many, or use of assistive devices;
· Endurance level; and
· Pain rating and how performance of MRADLs impacts this pain rating.
 
NAS also said it is seeing the use of supplier-generated forms. However, the notice added:
 
“Forms produced by the supplier for the face-to-face mobility exam do not record a complete medical examination and thus do not provide enough detailed information to adequately describe the medical necessity for the power mobility device in the beneficiary's home and are insufficient to meet the statutory requirements.
 
“Many suppliers have created forms which have not been approved by CMS which they send to physicians and ask them to complete. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record.”
 
The power chair documentation “should provide a clear, concise picture of the beneficiary's status,” the DME MAC said.   
 
Noridian said it had begun monitoring the K0823 (group 2 standard, captain's chair) claims because of a “high volume of claim errors” found by the Comprehensive Error Rate Testing (CERT) contractor.
 
Read the full notice on the NAS Web site.