TriCenturion delivers 'wake-up call' to rehab providers

Sunday, September 23, 2007

COLUMBIA, S.C. - The denial rate for the K0823 power wheelchair was a whopping 88% in Jurisdiction A and 93% for Jurisdiction B from Dec. 1, 2006, through March 31, 2007, according to the results of a pre-payment probe review by TriCenturion, the program safeguard contractor (PSC) for those jurisdictions.

As a result, all claims for K0823, a new code comparable for the infamous K0011, in jurisdictions A and B will be subject to review, TriCenturion stated in a September coding bulletin.

"I think this is a wake-up call for all of us that we need to do what the government wants us to do, whether we like it or not," said Tim Pederson, chairman of AAHomecare's Rehab and Assistive Technology Council (RATC) and CEO of WestMed Rehab in Rapid City, S.D. "There are a lot of providers who are worried now."

TriCenturion will send additional documentation requests (ADRs) to providers selected for review. Providers who receive ADRs must supply the requested information within 30 days.

Reasons for denials included failing to document dates of face-to-face evaluations and failing to submit detailed product descriptions.

While industry sources were surprised by some reasons for denial--"Things like date stamps--providers should have those down pat," said Don Clayback, who heads up The MED Group's rehab network--they weren't surprised by others. Under "Medical Records," TriCenturion detailed reasons like "supplier-created mobility evaluation forms were submitted as a substitution for information from the medical record."

"I think there's a need for clarity on the part of CMS to help resolve questions that providers and physicians still have about medical records," Clayback said.

Cara Bachenheimer, senior vice president of government relations for Invacare, agreed.

"It can't possibly be true that that number of wheelchairs were all medically unnecessary," she said. "(The results of the probe) speak to the subjectivity of some of the documentation requirements."

Bachenheimer urged providers to "be more diligent than ever" in documenting claims. Even though he's not in jurisdictions A or B, Pederson said he's conducting self-audits.

The immediate fallout of TriCenturion's probe is unclear, industry sources said.

"I'm hoping it's more educational than punitive in nature," Pederson said. "But my guess is they're going to want to take their money."