K0825 Prepayments Results For 3rd Quarter

Jurisdiction D performed a widespread prepayment review for K0825 during the third quarter.  The review involved 122 claims of which 93 were denied resulting in an overall error rate of 80%.   While this is an improvement from the 1st and 2nd quarters, which were 89% and 92% respectively, the primary reason for the denials were documentation errors.

31.5% – denied due to the documentation did not support that an optimally configured manual wheelchair was insufficient

12.5% – denied as the documentation did not support that a cane or walker was insufficient

10.6% – denied as no documentation was received

  8.3% – denied as documentation did not support that a POV was insufficient


The patient’s chart notes need to indicate why a cane or walker is not sufficient for the patient. Along with explaining why the patient does not have upper extremity strength to self-propel an optimally configured manual wheelchair in the home.  This includes charting limitation strengths, endurance, range of motion or coordination, pain, deformity, and/or any information to support the medical need of the item being ordered.  Also, need to make sure a POV has been considered and ruled out making sure this is documented in the chart notes.  All of this information needs to be documented in the chart notes explaining WHY.


Suppliers, please remember you need to respond to these auditors.  You are in violation of the Supplier Standards when you do not respond which could result in more audits and NSC notification. 


While this information is from Jurisdiction D, this is a good educational and training tool for your staff.  Be sure to share this information and to discuss this with all your staff.


For further questions, please contact Peggy Walker at peggy.walker@vgm.com or 800-401-3643 and Ronda Buhrmester at ronda.buhrmester@vgm.com or 888-665-6518.