TriCenturion Expands K0823 Probe; No Easy Button Here

TriCenturion Expands K0823 Probe; No Easy Button Here
COLUMBIA, S.C.–TriCenturion announced last week that it will
continue a widespread pre-payment review of K0823 power wheelchairs
after a probe review showed sky-high denial rates of 87.51 percent
for Jurisdiction A and 93.36 percent for Jurisdiction B. (See
HomeCare Monday, June 11.)

The Jurisdiction A/B DME program safeguard contractor said its
pre-payment review for the code–Group 2 standard captain’s chair
with patient weight capacity up to and including 300 pounds–will
continue in both regions.

“What this means is that the small sample size from the
widespread probe will be increased to encompass virtually all
claims for K0823 in Jurisdictions A and B,” said Tim Pederson, CEO
of WestMed Rehab, Rapid City, S.D., and chair of the American
Association for Homecare’s Rehab and Assistive Technology
Council.

In a bulletin posted on its Web site Sept. 17, a chart comparing
medical review determinations in TriCenturion’s pre-payment probe
showed that more than 60 percent of the claims in Jurisdiction A
and more than half in Jurisdiction B were denied as “non-covered.”
More than 30 percent of claims in Jurisdiction B and more than 10
percent in Jurisdiction A were denied as “not medically
necessary.”

A list of reasons TriCenturion gave for denials included
physician orders on which the date of the face-to-face evaluation
was not documented or there was no date stamp to verify the
supplier’s receipt within 45 days. Other reasons included that
functional limitations were not addressed in the evaluation, that
letters of attestation were submitted without supporting
information from the medical record and that some suppliers created
mobility evaluation forms as a substitute for information from the
medical record.

Issued last year, CMS’ new power mobility rule replaced the
power mobility CMN with a face-to-face exam and a doctor’s
prescription. But under new documentation requirements, providers
are responsible for gathering patient records that prove medical
necessity for the equipment.

Seth Johnson, director of government affairs for Pride Mobility
Products, Exeter, Pa., said the probe “speaks volumes about the
need for the policies and procedures currently in the interim final
rule to be reexamined. I think it also clearly shows the need for
CMS to do some extensive education with providers and, even more
importantly, with the physicians. Clearly, the documentation
expectations by the Medicare contractors are not clear to anyone
when you have denial rates in the 90-percentile range.

“The biggest complaint that we hear from providers is the
difficulty that they have in getting this information from
physicians,” Johnson continued. “Physicians just are not in the
practice of providing so much information for other items they
prescribe.”

Eric Sokol, executive director of the Power Mobility Coalition,
said the Washington-based organization has “real concerns” with
CMS’ lack of analysis of the paperwork burden on providers in
gathering PWC documentation. According to Sokol, while CMS said
there would be no tangible difference in the burden on suppliers
under the new rule as in obtaining a CMN, he said, “that is
certainly not the case.”

The coalition has submitted comments on the matter to the Office
of Management and Budget, which is currently reviewing the
paperwork burden, Sokol said.

“Right now, it’s just a documentation requirement that’s
amorphous, that’s never-ending as far as what CMS wants, and it
creates a claims processing system where CMS holds all the cards
and all the claim reviews are subjective,” Sokol said. He added
that he hopes CMS will work with the industry to come up with a
tool where a physician could complete all necessary steps, then the
provider could submit that along with any supporting documentation
and have “a reasonable expectation of payment.”

Pederson said the degree to which physicians, therapists and
providers are confused about PWC documentation requirements should
be more certain after providers complete the appeals process on
claims denied in the preliminary probe. “Certainly these providers
will appeal the findings of the probe,” Pederson said. “It will be
interesting to follow the group of claims through the appeal
process to find out what the final percentage of denials ends up to
be.”

In addition, Pederson said, “we need to know what the final
medical necessity denial rate is versus [the] documentation error
rate.” That data, he said, “will tell us what the shortcomings are
of the educational efforts of CMS, manufacturers, trade
associations, group purchasing organizations and providers
themselves …

“We need to keep in mind that the overhaul of the power mobility
device policy was sweeping and comprehensive,” Pederson continued.
“It is evident that at least some of the providers in our industry
did not adequately prepare for providing power wheelchairs under
our new reality … Personally,” he added, “I think we are seeing
the results of what happens to those providers who respond by
wishing for the ‘easy button’ instead of facing our current reality
and changing the way they do business.”

Pederson said the industry is seeing PMD utilization down
“around 20 percent from two years ago. This is a direct result of
the new PMD policies and their related documentation requirements.
We can’t wish this situation away. We need to move forward and do
what is asked of us or we will not get paid or be allowed to keep
our payments after an audit.”

TriCenturion said providers whose claims are selected for review
will receive an Additional Documentation Request letter “asking for
specific information to determine if the item billed complies with
the existing reasonable and necessary criteria.” Failure to supply
the information within 30 days of the request will result in denial
of the claim, the PSC said.

View the TriCenturion bulletin in full.