How to Reduce Power Chair Denials

When billing CMS for DME claims, documentation is the name of the game, and no other piece of medical equipment better exemplifies this than power wheelchairs. If a provider forgets one dotted “i” or one crossed “t,” it can result in that funding taken off its books while Medicare audits the claim.

This represents a steep learning curve for many providers. For instance, a first-quarter review of some baseline audits performed in regions A and B on standard Group 2 standard power wheelchair code K0823, which was released in December 2007, showed that the audit rates for each were 87.51 percent and 93.36 percent, respectively.

So how can providers minimize denials of power chair claims?

Get the documentation right. As file claims that amount to thousand of dollars that claim will get paid, unless the claim is pulled to undergo a pre- or post-pay audit. “It’s in those two audit situations that providers can run into trouble,” says Georgie Blackburn, vice president of government relations and legislative affairs for Pittsburgh-based provider Blackburns. “But if all the pieces fit the puzzle, you’ll sail through an audit.”

Coordinate with the physician. Don’t assume the doctor will know your documentation needs. When a provider sends a patient to a physician, it should send the doctor information that helps him or her comply with Medicare policy and helps the provider work smoothly with clinicians who might be involved in the process. Then the doctor will write the order and send all the data, the chart notes from the physical exam, and copies of the clinical team’s report to the provider.

Have the correct face-to-face date. A key element of that report is the face-to-face date. With the new national coverage decision on mobility-assisted equipment, providers submitting claims for power mobility must submit evidence of the examination or clinical assessment with an order that documents the face-to-face date when the patient met with the physician or clinician to determine what the equipment specification should be, Blackburn says.

Just make sure it’s the correct date. There are, in fact, five scenarios for face-to-face dating, depending on the situation, according to Blackburn:
1. The date the physician sees the patient and performs the entire physical exam and assessments for the purpose of mobility at one time is the face-to-face date.
2. The physician sees the patient, but determines a clinical assessment is required. The report of the assessment is sent back to the doctor, who must state concurrence or disagreement with the report, and —sign and date the report. The date the doctor signs concurrence is the correct face-to-face date.
3. The physician sends the patient for the assessment prior to seeing the patient for the exam. When the report is sent to the physician, he or she must see the patient. The date the physician physically sees the patient and signs concurrence with the clinician report is the face-to-face date.
4. The patient has been in skilled care, and the physical exam and clinical assessment have taken place during the inpatient stay. The patient’s discharge date would be the correct face-to-face date.
5. The patient’s primary care physician decides to send the patient for a clinical assessment that is staffed by a clinician (PT or OT) and a physician. In such cases, the entire physical exam and clinical assessment can be completed at the same time and that date is the correct face-to-face date. The physician at the clinic is actually the prescribing physician.

Date stamp everything. The provider has 45 days from the face-to-face date for the doctor to get the order to the provider; the provider has120 days from the face-to-face date to deliver the equipment; and, if a provider submits a prepackage review to Medicare to analyze ahead of time if the patient meets medical necessity requirements, then the provider has six months from the determination date to deliver that DME. “In audit, they’re going to be looking at those timelines,” Blackburn says.

Have a savvy team. “There a lot of pitfalls in this if you don’t have a well-oiled team analyzing the documentation as it comes in,” Blackburn says. Provider staffers need to understand the medical terminology and acronyms doctors and clinicians use to ensure it meets policy. Otherwise the provider risks an audit. Ensure you have detail-oriented staff, train them in power mobility and Medicare policy, and then validate that training was effective.

Perform a home assessment.
Prior to at point of the delivery, there must be an assessment of the patient’s home to demonstrate the patient’s need for the power mobility device in order to perform the tasks of daily living. This includes measurements of items such as doorways and thresholds, types of surfaces, navigable floor space, and hall widths.

Provide a supplier attestation.
This simply says that the physician has no financial relationship with the provider and must be signed by the provider. This will be requested in an audit.

Points to take away:

•    The name of the game is internal quality and assurance:
•    Know the documentation requirements.
•    Coordinate with the physician to ensure you get the right documentation.
•    Have the right face-to-face date on the order.
•    Date stamp the whole way through.
•    Hire a savvy team to review all documentation.

This article originally appeared in the July 2008 issue of HME Business.


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