In recent days, the Association has recorded complaints about:

• Patient confusion or dissatisfaction about the need to switch HME providers,
• Delayed discharge from facilities,
• Admission to hospital because of no access to HME,
• Problems coordinating delivery of items,
• Companies laying off employees, and
• Questions for the Competitive Bidding Implementation Contractor that go unanswered.

Please use the flyers found on AAHomecare's blog to spread the word about the toll-free complaint number and website. HME providers, patients, caregivers, and professions in the healthcare continuum need to know how to report concerns about the bidding program.

The second quarter edit effectiveness results from September 2010 through November 2010 are as follows:

The results of the review of the claims identified 253 claims of which 232 were denied. This resulted in an overall error rate of 92%.

The following are the top reasons for denial:

• Insufficient medical records submitted to justify the medical necessity for the wheelchair and required documentation not submitted in full or was not complete
• Medical records did not include the basic policy coverage criteria A-C
• No evidence of a face-to-face examination
• No home assessment completed
   
• No valid written order
• No written order submitted with the documentation
• No dispensing order submitted, only a detailed product description (DPD) that was completed by the supplier
• Name of ordering physician was not legibly identified

Although the error rate remains high, NAS will discontinue the review due to upcoming changes in payment for this item. NAS will continue to monitor the billing patterns of this and all power mobility devices to determine if further review is necessary.

As a reminder, the Local Coverage Determination (LCD) for Power Mobility Devices (L23598) states in part:

BASIC COVERAGE CRITERIA:

All of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered.

A. The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:

• Prevents the patient from accomplishing an MRADL entirely, or
  Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
• Prevents the patient from completing an MRADL within a reasonable time frame.

B. The patient's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.

C. The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.

• Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
• An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in Power Mobility Devices Local Coverage Determination (LCD) L23598 and Policy Article A41127. Suppliers can review the Group 1 Power wheelchairs (K0813-K0816) and Group 2 Power wheelchairs (K0820-K0829) documentation checklist on the NAS website here.

Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3 located here.

Two of the required elements of the DPD are the supplier's submitted charge and the Medicare fee schedule allowance. Medicare fee schedule allowances typically change with a new calendar year and may be revised at other times. If the supplier's submitted charge and fee schedule allowance are correct at the time that the DPD is signed by the physician but change prior to delivery of the PMD, the supplier is not required to obtain a new DPD. Also, if the DPD was completed in 2010 based on the submitted charge and fee schedule allowance for a purchased PMD, a new DPD is not required if the PMD is delivered in 2011 and billed as a rental. (Refer to Power Mobility Devices LCD for additional information relating to DPDs.)