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Home Health & Hospice Week

Medical Review:

HOW TO SURVIVE A PRE-PAYMENT AUDIT FOR WHEELCHAIRS

Published on Thu Jul 22, 2004

With the right documentation, suppliers can get through and get paid.

Are you suffering through a prepayment audit of your power wheelchair claims? If so, you're not alone.

Thanks to Operation Wheeler Dealer, new and experienced suppliers alike are getting slapped with prepayment audit status when claims exceed a certain dollar amount.

So, how do you get through the audit with your business intact? Make sure your response to that audit letter is as seamless as possible, advises Tammany Mills, president and owner of DME Billing Solutions.

Missing or incomplete information on the certificate of medical necessity amounts to an automatic denial for lack of medical necessity, Mills said in a June teleconference sponsored by Eli Research and The Coding Institute. And scores of claims tied up in medical review for months on end could spell a death sentence for a durable medical equipment supplier.

Mills outlined the documentation Medicare is looking for in your audit response. Be sure to include:

  • the CMN, including 1) the initial date on or before the date of service; 2) nothing left blank on sections A, B and C; and 3) a doctor's signature within three months of the date of service;
  • physical therapy or occupational therapy notes, if they discuss the functional level of the beneficiary and are prior to the initial date on the CMN;
  • medical records from the physicians, the hospital, the home health agency or the nursing home, prior to the initial CMN date. These records should include the need for each individual accessory you itemize when you bill the claim;
  • a letter of medical necessity from the doctor. This isn't mandated but can be very helpful, Mills said;
  • the manufacturer's name and product number, your invoice and the suggested retail price; and
  • a description of the patient's routine activities outside the home. Again, this isn't a strict requirement but can help you pass review, Mills noted.

    Remember: The message you want to get across is that the patient was evaluated for this equipment long before you came on the scene. "All Medicare wants to know is that this power wheelchair was the doctor's idea and not the supplier's," Mills said.

    Editor's Note: To obtain a recording or transcript of Mill's teleconference, call The Coding Institute at 1-800-508-2582 or visit http://codinginstitute.com/conference/tapes.cgi?detail=619.

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