HCPCS Code K0823 – Service Specific Pre-Pay Review

CIGNA Government Services, the Jurisdiction C DME MAC, will be implementing a service-specific prepayment edit for Healthcare Common Procedure Coding System (HCPCS) code K0823 (Power wheelchair, Group 2 standard, captains chair, patient weight capacity up to and including 300 pounds). This edit is the result of data demonstrating a high claims payment error rate for this power wheelchair product category.

Claims subjected to this edit will be developed for additional documentation. Suppliers receiving a development letter should follow the instructions contained in the letter for the specific documentation requested. Suppliers will be asked to submit documentation including, but not limited to:

  • Physician’s Order
  • Detailed Product Description
  • In-home Assessment
  • Documentation of Face-to-Face Evaluation
  • Medical Record Documentation of Medical Necessity
  • Proof of Delivery and Product Information

The information must be received within 30 days of the date of the letter or the claim will be denied.

Suppliers are reminded that medical necessity documentation (e.g., notes from prior visits, test reports, etc.) must be obtained from the treating physician to provide a historical perspective that reflects the patient’s condition in the continuum of care, corroborating the information in the face-to-face examination, painting a picture of the patient’s condition and progression of disease over time.

Additional information on this and other documentation requirements for code K0823 may be found on the CGS Medical Review web site at:

www.cignagovernmentservices.com/jc/coverage/mr/power_mobility_resources.html

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