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By Kim Turner, RN, Clinical Consultant and Lisa Eick, RN, Clinical Consultant If you provide complex rehabilitative equipment to Medicare beneficiaries, you are likely familiar with the Medicare Prior Authorization Requests program 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 K0856 and K0861 for dates of service on or after July 17, 2017. While this is undoubtedly a valuable service, what is widely misunderstood is that, as a condition of payment for Prior Authorization, the DME MACs review the specialty evaluation “to determine the beneficiary’s medical necessity for the “power wheelchair base unit only”. The prior authorization process does not include review of the specialty evaluation to determine the beneficiary’s medical necessity for the related wheelchair options and accessories and/or wheelchair seating.  Further, similar to the review procedures for Advanced Determination of Medicare Coverage (ADMC), the prior authorization process for K0856 and K0861 does not include the consideration of same/similar equipment already in use and on file with Medicare. 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 costly denials and potential overpayments.

What are benefits of our prescreen services prior to sending documents to prior authorization?

  • Same/similar equipment review
    • 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, we review your medical records to ensure that they clearly document a significant change or decline in the beneficiary’s’ condition that would justify and support new equipment in less than 5 years.
  • Face to face examination and the LCMP specialty evaluation review
    • Our clinicians determine 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 another audit entity requests the medical records during a pre- or post-payment claim audit.
  • ATP Evaluation review to ensure that the ATP’s participation in the selection of equipment is properly documented and satisfies Medicare ATP guidelines.
  • Review of the home evaluation to ensure the document contains all the required information, such as room measurements, and the document has been signed and dated.

What are the consequences of insufficient medical records in the post-payment environment?

  • Extra time and work to prepare and submit for appeal.
  • Full or partial overpayment of monies allowed in error. If you receive an overpayment, you are obligated to refund the money. It is in your best interest to immediately refundthe 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.
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. Want to feel confident that the power wheelchairs and accessories you are providing meet coverage criteria? Sign up for our clinical prescreen services. Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our prescreen program. Contact us for more information!  
*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.