van Halem Group

By Kim Turner, RN

By now as a complex rehab supplier, you are likely familiar with and even utilizing the Medicare Condition of Payment Prior Authorization (PA) Requests for the K0856 - Group 3 standard, single power option and the K0861 Group 3 standard multiple power option wheelchairs. The program began for all suppliers for the PMD HCPCS K0856 and K0861 for dates of service on or after July 17, 2017. Further, to expand on the success of the PA program, CMS has transitioned the eligible HCPCs codes K0813-K0829 and K0835-K0855 formerly known as PMD PA Demonstration which ended August 31, 2018, to the required program nationwide Condition of Payment Prior Authorization program effective September 01, 2018.
For complex rehab suppliers billing CGS DME MAC Jurisdictions B and C, the following are the top non-affirmative decision reasons for the Expanded Condition of Payment Prior Authorization for CGS DME MAC Jurisdictions B and C, including information and resources to decrease the non-affirmative decisions.

7-Element Order and Face-to-Face

• The 7-element order was not written by the same physician/practitioner that completed the face-to-face examination.

Payment may not be made for a motorized or power wheelchair unless the practitioner who has conducted the face-to-face examination him or herself writes the 7-element order. It is a statutory requirement that all items of the 7-element order be entered specifically by and only by the practitioner who has conducted the face-to-face requirements.

• 7-element order did not include a valid face-to-face date or was dated prior to the completion of the face-to-face requirements.

For a Power Wheelchair (PWC) to be covered the treating practitioner must conduct a face-to-face examination of the beneficiary before writing the order and the supplier must receive a written report of this examination within 45 days after completion of the face-to-face examination and prior to delivery of the device.

The supplier did not receive a valid copy of the 7-element order within 45 days after the completion of the face-to-face examination.
The supplier must receive a written report of this examination within 45 days after completion of the face-to-face examination and prior to delivery of the device.
A date stamp or equivalent must be used to document receipt date.

The face-to-face examination was not signed; therefore, the identity and credentials of the author cannot be authenticated.
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author.
The method used shall be a handwritten or electronic signature. Additional information regarding signature requirements is located in the CMS Fact Sheet: Complying with Medicare Signature Requirements
A signature attestation may be submitted along with unsigned medical records to fulfill the signature requirements.

• The face-to-face examination does not paint a clear picture of the beneficiary's functional abilities and limitations or demonstrate use of a POV has been excluded.

There must be an in-person visit with a clinician specifically addressing the patient's mobility needs.
There must be a history and physical examination by the clinician or other medical professional focusing on an assessment of the patient's mobility limitation and needs. The results of this evaluation must be recorded in the patient's medical record.
The history should paint a picture of your patient's functional abilities and limitations in their home on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient's ambulatory difficulty or impact on the patient's ambulatory ability. Vague terms such as "difficulty walking" or "upper extremity weakness" are insufficient, since they do not objectively address the mobility limitation or provide a clear picture of the patient's mobility deficits in participating in MRADLs.

• The documentation did not include a financial attestation stating the licensed/certified medical professional (LCMP) has no financial relationship with the supplier.

If the report of an examination is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier or LCMP that the LCMP has no financial relationship with the supplier.

Documentation Requirements

• The documentation did not demonstrate the need for a sling/solid seat/back wheelchair.

A power wheelchair with Captain's Chair is not appropriate for a beneficiary who needs a separate wheelchair seat and/or back cushion. If a skin protection and/or positioning seat or back cushion that meets coverage criteria (see Wheelchair Seating LCD) is provided with a POV or a power wheelchair with Captain's Chair, the POV or PWC will be denied as not reasonable and necessary. (Refer to Wheelchair Seating LCD and Policy Article for information concerning coverage of general use, skin protection, or positioning cushions when they are provided with a POV or power wheelchair with Captain's Chair.)
For beneficiaries who do not have special skin protection or positioning needs, a power wheelchair with Captain's Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain's Chair, the wheelchair and the cushion(s) will be covered only if either criterion 1 or criterion 2 is met:
The cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair model – i.e., codes K0839, K0840, K0843, K0860 – K0864, K0890, K0891; or
A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.

• The documentation does not demonstrate the beneficiary meets the coverage criteria for a power tilt and power recline seating system and the system is being used on the power mobility device.

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and
A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and
The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
The power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

• The documentation contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles.

Documents containing amendments, corrections or addenda must:
- Clearly and permanently identify any amendment, correction ordelayed entry as such, and
- Clearly indicate the date and author of any amendment, correction or delayed entry, and
- Clearly identify all original content, without deletion.

Detailed Product Description (DPD)

• The DPD was incomplete or did not include a date stamp or equivalent.

Once the specific power mobility device that is appropriate has been determined based on the practitioner's 7-element order, the supplier must prepare a Detailed Product Description (DPD) that complies with the requirements for a detailed written order as outlined in the Supplier Manual and CMS' Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5.
Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.
The practitioner must sign and date the detailed product description and the supplier must receive it prior to delivery of the PWC or POV. Signature and date stamps are not allowed.
A date stamp or equivalent must be used to document the supplier receipt date.

Lack of a complete and thorough review of the medical records for wheelchair options and accessories, leaves the supplier vulnerable for potential overpayments in the event of a post payment audit. The van Halem Group is here to help you reduce the risk of what could amount to a substantial repayment to Medicare.

What are benefits of van Halem Group prescreen services prior to sending documents to prior authorization?

vHG requires and reviews the IVR print out as part of the prescreen review process.
- The IVR documents any same/similar equipment already in use that may be less than 5 years old.
- Also, if there is same/similar equipment already in use, vHG then reviews the medical records to ensure that the records clearly document a significant change or decline in the beneficiary’s’ condition that would justify and support new equipment in less than 5 years.
vHG -requires and reviews the face to face examination and the LCMP specialty evaluation as part of the prescreen review process.
- vHG determines if the recommended (or ordered) power wheelchair base, all related options and accessories, and/or all wheelchair seating are sufficiently justified and supported in the medical records.
- This allows the supplier to include the required KX modifier with confidence that the medical records document sufficient justification should Medicare or other audit entity requests the medical records during a pre or post payment claim audit.
vHG requires and reviews the ATP Evaluation to ensure that the ATP’s participation in the selection of equipment is properly documented and satisfies Medicare ATP guidelines.
vHG reviews the home evaluation as part of the prescreen review process
- This helps to ensure the document contains all the required information such as room measurements and the document has been signed and dated.
An additional benefit of vHG prescreen review, is the valuable staff education regarding the Medicare coverage and payment guidelines and recent updates to the LCDs, policy articles, and HCPC billing codes.

What are the consequences of insufficient medical records following a Medicare or other audit entity post payment?

Extra time and work to prepare and submit for appeal.
Full or partial overpayment of monies allowed by Medicare in error.
If you receive an overpayment, you are obligated to refund the money to Medicare.
It is in your best interest to immediately refund the requested amount. This will help you avoid an offset and accruing interest. Risk of denial for improper use of KX modifier. Many policies use the KX modifier to indicate compliance with specified coverage criteria. Proper use of the KX modifier expedites claim processing. Increasing numbers of claims are submitted without the modifier resulting in a growing appeals volume.

The overall big picture for Medicare is the post payment audit, which is where overpayments are determined. To avoid becoming susceptible to Medicare overpayments, the van Halem Group can provide you prescreen services to help reduce risk of losing Medicare dollars for seating and accessories that are not reviewed during prior authorization.

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