Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
M P
EDICARE  AYMENTS FOR 
P W
OWER  HEELCHAIRS 
Inspector General 
April 2004 
OEI-03-02-00600  Office of Inspector General

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs. This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 
and program evaluations (called inspections) that focus on issues of concern to the 
department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. The OI also oversees 
state Medicaid fraud control units, which investigate and prosecute fraud and patient 
abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations. The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department. The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the 
health care community, and issues fraud alerts and other industry guidance.    A B S T R A C T

In 2001, Medicare and its beneficiaries paid $513 million for all K0011 
power wheelchairs. Payments for this procedure code have risen 
dramatically, increasing 43 percent from the year 2000 to 2001 alone. 
In order to determine whether K0011 power wheelchairs provided in 
2001 met Medicares coverage and documentation requirements, we 
selected a simple random sample of 300 claims. We then contacted the 
suppliers, ordering physicians, and beneficiaries associated with these 
claims, and provided medical documentation to an independent 
contractor for a coverage review. Our review indicated most claims did 
not meet Medicares coverage criteria for K0011 power wheelchairs; 
however, some claims met criteria for a less expensive mobility device. 
We also identified a number of other problems with Medicare claims for 
K0011 power wheelchairs, including missing and incomplete supporting 
documentation, and equipment that is not used by Medicare 
beneficiaries. We recommend that the Centers for Medicare & Medicaid 
Services (CMS) improve compliance with Medicares coverage criteria 
for power wheelchairs. We suggest that CMS require durable medical 
equipment regional carriers to revise current coverage policies for power 
wheelchairs; conduct frequent reviews of K0011 claims; and educate 
ordering physicians and beneficiaries about power wheelchair coverage 
criteria. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  i    E X E C U T I V E   S U M M A R Y

OBJECTIVE 
To determine whether power wheelchair claims meet Medicares 
coverage and documentation requirements, and to examine 
beneficiaries use of equipment and selection of suppliers. 
BACKGROUND 
Title XVIII of the Social Security Act established coverage and benefits 
under Part B of the Medicare program. Medicare beneficiaries covered 
by Part B are eligible to receive durable medical equipment (DME), such 
as power wheelchairs, when the items are deemed medically necessary 
by a physician and needed for use in the home. To qualify for power 
wheelchairs, patients must be bed or chair confined, unable to operate a 
wheelchair manually, and capable of safely operating the controls of the 
power wheelchair. 
According to supplier manuals published by the durable medical 
equipment regional carriers (DMERCs), initial claims for power 
wheelchairs must include a Certificate of Medical Necessity (CMN) that 
has been signed and dated by a physician. The supplier must maintain 
a copy of this signed CMN in their records. Suppliers must also 
maintain documentation showing that items were delivered to 
beneficiaries. 
In calendar year (CY) 2001, Medicare and its beneficiaries paid a total 
of $513 million for procedure code K0011, a standard-weight power 
wheelchair with programmable control parameters. Medicare allows 
approximately $5,000 for each K0011 power wheelchair claim. Total 
allowances for the K0011 code have risen dramatically, increasing 
43 percent from the year 2000 to 2001 alone. Although many 
beneficiaries need power wheelchairs, DMERCs and the Office of 
Inspector General (OIG) have identified fraud cases involving power 
wheelchairs that were not supplied, not medically necessary, or both. 
For this inspection, we selected a simple random sample of 300 claims 
for procedure code K0011 from the Centers for Medicare & Medicaid 
Services (CMSs) 2001 National Claims History File. We then collected 
CMNs and delivery documentation from suppliers, and medical records 
from ordering physicians. Using Medicare coverage criteria, an 
independent medical review contractor conducted a coverage review of 
medical records received from physicians or suppliers. We did not assess 
the appropriateness of the Medicare coverage criteria themselves. We 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  ii  E X E C U T I V E   S U M M A R Y  
also spoke with 166 of the 300 beneficiaries on whose behalf Medicare 
paid sample claims. 
FINDINGS 
Most reviewed claims did not meet Medicares coverage criteria for 
a K0011 power wheelchair; however, some claims may have met 
coverage criteria for a less expensive mobility device. Almost one-
third of reviewed claims did not meet Medicares coverage criteria for 
any type of wheelchair. An additional 45 percent of reviewed claims did 
not meet Medicares coverage criteria for the K0011 power wheelchair 
but may have met criteria for another type of wheelchair or scooter (also 
known as a power-operated vehicle). Physicians, however, may not be 
familiar with Medicares coverage criteria when ordering mobility 
devices for their patients. The only document that physicians are 
required to review and complete when ordering a wheelchair is the 
CMN. Coverage guidelines are not listed on the CMN for power 
wheelchairs, and medical necessity questions on CMNs are not totally 
consistent with coverage policy. In CY 2001, Medicare and its 
beneficiaries paid an estimated $178 million for claims that did not 
meet Medicares coverage criteria for K0011 power wheelchairs.  Only 
13 percent of reviewed claims actually met the coverage criteria for 
K0011 power wheelchairs. Due to insufficient documentation, the 
reviewer could not determine whether another 11 percent of reviewed 
claims met the coverage criteria for the K0011 power wheelchair. 
For over half of claims, CMNs and/or delivery documentation were 
missing, incomplete, or dated after the date of service. For 5 percent 
of K0011 power wheelchair claims, suppliers did not provide a CMN 
and/or proof of delivery. We estimate that Medicare and its 
beneficiaries paid an additional $19 million in CY 2001 for K0011 
claims that could not be substantiated by either a CMN or delivery 
documentation. Even when suppliers did submit CMNs or proof of 
delivery, the documentation was often incomplete or dated after the 
date of service. 
Most responding beneficiaries reported using their power 
wheelchairs at home; other beneficiaries either do not use their 
power wheelchairs or use them for outside activities only. Sixty-
eight percent of beneficiaries who responded to our survey (113 of 166) 
currently use their power wheelchairs inside their homes. Four percent 
of respondents said that they have never used their power wheelchairs. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  iii  E X E C U T I V E   S U M M A R Y  
An additional 12 percent of respondents said that they do not currently 
use their power wheelchairs but have used them in the past. Another 
12 percent of respondents reported that they currently use their power 
wheelchairs outside the home only. 
Many beneficiaries who completed our survey responded to 
suppliers direct marketing practices. Almost one-quarter of 
beneficiaries who responded to our survey learned about their power 
wheelchair suppliers from a television commercial. An additional 
9 percent of respondents chose their suppliers after receiving something 
in the mail. Another 4 percent of respondents obtained their power 
wheelchairs from suppliers who visited their homes. 
RECOMMENDATION 
A power wheelchair can greatly improve the quality of life for an 
individual who otherwise suffers from limited mobility. However, our 
coverage review indicates that Medicare and its beneficiaries spent an 
estimated $178 million in 2001 for K0011 power wheelchairs that did 
not meet Medicares coverage criteria. These inappropriate payments 
waste taxpayer dollars that could otherwise fund appropriate 
equipment for needy Medicare beneficiaries. 
CMS has recognized the dramatic growth in payment for and utilization 
of power wheelchairs and is currently taking steps to address these 
issues as part of its 10-point plan of action to curb power wheelchair 
fraud, waste, and abuse. In fact, CMS has already begun implementing 
some of the options listed in the following recommendation. We believe 
that continued attention to Medicare payments for K0011 power 
wheelchairs is warranted. 
We recommend that CMS improve compliance with Medicares 
coverage criteria for K0011 power wheelchairs. CMS should consider 
the following options in order to improve compliance: 
Require DMERCs to revise the coverage policy for K0011 power wheelchairs 
to include specific information about the medical conditions for which Medicare 
will cover this item. Our findings show that many beneficiaries did not 
meet coverage criteria for the K0011 power wheelchair but may have 
qualified for a lower-priced power wheelchair, a scooter, or a manual 
wheelchair. Given that patients frequently received K0011 power 
wheelchairs when their conditions warranted a lower level of 
equipment, CMS should evaluate the medical conditions and functional 
abilities that are associated with different types of mobility aids and 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  iv  E X E C U T I V E   S U M M A R Y  
describe these conditions/abilities in the coverage policies. This will 
ensure that beneficiaries have access to the equipment that is most 
appropriate for their conditions. DMERCs should also consider 
removing guidelines regarding the specialties of physicians who order 
scooters. In addition, DMERCs should require that physicians treat the 
patients for whom they order equipment. 
Require DMERCs to conduct frequent reviews of the K0011 procedure code to 
ensure appropriate payments. When performing reviews of K0011 claims, 
DMERCs should ensure that suppliers have complete and thorough 
documentation. DMERCs should also request medical records from 
ordering physicians in addition to supporting documentation from 
suppliers. DMERCs should also consider routinely contacting 
beneficiaries during the course of reviews to ensure that the equipment 
provided by suppliers is appropriate for and useful to beneficiaries. 
Educate ordering providers about Medicares coverage criteria for different 
types of assistive devices, including power wheelchairs, manual wheelchairs, 
and scooters. Ordering providers play a key role in determining the 
need for and utilization of equipment billed to Medicare. According to 
the Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, payment may not be made for power wheelchairs unless a 
physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist has conducted a face-to-face examination of the patient and 
written a prescription for the item. CMS relies on the clinical judgment 
of these health care professionals to ensure that Medicare only pays for 
items that are most appropriate for beneficiaries. However, ordering 
providers may not be aware of Medicares coverage requirements for 
mobility devices. A lack of provider education about Medicares 
coverage criteria for wheelchairs could adversely affect physicians 
ability to make informed decisions about the types of mobility devices 
that are best for their patients, which could ultimately lead to 
inappropriate Medicare payments. 
Educate Medicare beneficiaries about coverage criteria for wheelchairs and 
scooters. Beneficiaries also play a key role in ensuring that Medicare 
does not pay for medically unnecessary or unused items. Beneficiaries 
who are knowledgeable about Medicares coverage guidelines can make 
more informed choices about the assistive devices that would meet both 
their own needs and Medicares coverage requirements. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  v  E X E C U T I V E   S U M M A R Y  
AGENCY COMMENTS 
CMS concurred with our recommendation and agreed with our 
suggestions regarding coverage policy revisions and provider and 
beneficiary education. They also agreed that more frequent reviews of 
the K0011 code will help ensure appropriate payments; however, they 
do not believe that routinely contacting beneficiaries would yield 
meaningful results. CMS confirmed that they have already begun 
implementing many of our report recommendations through their power 
wheelchairs workgroup, which was established to develop a plan of 
action to ensure that payments are only made for power wheelchairs 
that are reasonable and necessary. Specific actions by CMS include: 
requiring DMERCs to develop a complete picture of a patients medical 
condition before making medical review coverage determinations; 
developing a regulation to remove the current requirement that scooters 
be prescribed only by certain specialists; and developing a regulation 
that requires a face-to-face examination by the treating physician prior 
to ordering a power wheelchair. CMS is also poised to release an 
educational campaign designed to provide both physicians and 
beneficiaries with needed information regarding Medicare and DMERC 
coverage policy. The full text of CMSs comments is presented in 
Appendix B. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  vi    T A B L E   O F   C O N T E N T S

A B S T R A C T  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .   i

E X E C U T I V E   S U M M A R Y  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .  ii

I N T R O D U C T I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .  1

F I N D I N G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .  9

K0011 claims that did not meet Medicare coverage guidelines ........ 9

Missing, incomplete, or post-dated documentation ......................... 12

Beneficiaries reported use of power wheelchairs ............................ 13

Beneficiaries responded to direct marketing practices....................14

R E C O M M E N D A T I O N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .  16

A G E N C Y   C O M M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .  17

A P P E N D I C E S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .   19

A:  Estimates and Confidence Intervals .......................................... 19

B: CMSs Comments........................................................................ 20

A C K N O W L E D G E M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .  23
   I N T R O D U C T I O N

OBJECTIVE 
To determine whether power wheelchair claims meet Medicares 
coverage and documentation requirements, and to examine 
beneficiaries use of equipment and selection of suppliers. 
BACKGROUND 
Title XVIII of the Social Security Act established coverage and benefits 
under Part B of the Medicare program. Medicare beneficiaries covered 
by Part B are eligible to receive durable medical equipment (DME) 
deemed medically necessary by a physician. Medicare Part B classifies 
certain items of DME, such as wheelchairs, as capped rental items. 
Payments for capped rental items are made on a monthly basis not to 
exceed 15 continuous months; however, power wheelchairs may be 
purchased outright. A DME supplier must give beneficiaries that 
qualify for a power wheelchair the option to purchase the item when it 
is first provided. If the beneficiary chooses to purchase the power 
wheelchair at that time, the supplier receives a lump-sum payment. 
Medicare beneficiaries are responsible for 20 percent of this lump-sum 
payment in the form of coinsurance. 
To obtain reimbursement for medical equipment such as power 
wheelchairs, suppliers submit claims to one of four durable medical 
equipment regional carriers (DMERCs). The Centers for Medicare & 
Medicaid Services (CMS) contracts with these DMERCs to process and 
pay medical equipment claims. 
Medicare Coverage Criteria for Wheelchairs and Scooters 
Medicare covers many different types of wheelchairs, from basic manual 
wheelchairs and scooters (also known as power-operated vehicles) to 
high-end power wheelchairs. Section 1862(1)(A) of the Social Security 
Act states that all DME items provided under Medicare Part B, 
including wheelchairs and scooters, must be reasonable and necessary 
for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. In addition, Section 1861(n) 
of the Social Security Act stipulates that patients must need the 
equipment for use in their homes. Payment is approved for the least 
costly medically acceptable item. Options that are beneficial primarily 
in allowing beneficiaries to perform leisure or recreational activities are 
not covered by Medicare. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  1  I N T R O D U C T I O N  
Coverage Criteria for Manual Wheelchairs. A manual wheelchair is covered 
if the patients condition is such that without the use of a wheelchair, 
the patient would otherwise be bed or chair confined. Additional 
criteria may apply for non-standard manual wheelchairs such as 
lightweight, ultra-lightweight, and heavy-duty manual wheelchairs. 
Coverage Criteria for Scooters. Unlike other mobility devices covered by 
Medicare, a scooter must be prescribed by a specialist. A scooter is 
usually covered only if it is ordered by a physician in one of the 
following specialties: Physical Medicine, Orthopedic Surgery, Neurology, 
or Rheumatology. For coverage of scooters, all of the following 
additional criteria must be met: 
o	 The patients condition is such that, without the use of a 
wheelchair, the patient would not be able to move around in their 
residence. 
o  The patient is unable to operate a manual wheelchair. 
o	 The patient is capable of safely operating the controls for the 
scooter. 
o	 The patient can transfer safely in and out of the scooter and has 
adequate trunk stability to be able to safely ride in the scooter. 
Coverage Criteria for Power Wheelchairs. A power wheelchair is covered 
when all of the following criteria are met: 
o	 The patients condition is such that, without the use of a 
wheelchair, the patient would otherwise be bed or chair confined. 
o	 The patients condition is such that a wheelchair is medically 
necessary, and the beneficiary is unable to operate a wheelchair 
manually. 
o	 The patient is capable of safely operating the controls for the 
power wheelchair. 
According to the DMERC supplier manuals, A patient who requires a 
power wheelchair usually is totally non-ambulatory and has severe 
weakness of the upper extremities due to a neurologic or muscular 
disease/condition. Unlike scooters, a physician does not need to have a 
particular specialty in order to prescribe a power wheelchair. 
Documentation Required by DMERCs for Power Wheelchair Claims 
According to the DMERC supplier manuals, initial claims for power 
wheelchairs must include a Certificate of Medical Necessity (CMN). 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  2  I N T R O D U C T I O N  
These initial CMNs are usually submitted to DMERCs electronically. 
The CMN for power wheelchairs, CMS Form 843, is divided into 
different sections. Suppliers complete sections relating to their 
company, the beneficiary, and the ordering physician. They also provide 
information about the type of equipment ordered, their charge for the 
equipment, and the Medicare allowance. The ordering physician or an 
employee of the physician completes sections regarding the patients 
medical condition. In order for a power wheelchair to be covered by 
Medicare, the physician must respond, Yes to the following questions 
on the CMN: 
o	 Does the patient require and use a wheelchair to move around in 
their residence? 
o	 Does the patient have severe weakness of the upper extremities 
due to a neurologic, muscular, or cardiopulmonary 
disease/condition? 
o  Is the patient unable to operate any type of manual wheelchair? 
The ordering physician must then sign and date the CMN. The supplier 
must maintain a hard copy of this signed CMN in its records and 
present it to the DMERC upon request. Information submitted to the 
DMERC by the supplier must be substantiated by documentation in the 
patients medical records. 
According to the Medicare Program Integrity Manual and the supplier 
manuals, suppliers must also maintain documentation showing that 
items were delivered to beneficiaries. Delivery documents must include 
the date of delivery, the patients name and signature, the quantity of 
the item(s) delivered, a detailed description of the item(s) delivered, and 
the brand name and serial number of the item(s). Proof of delivery 
must be available to the DMERC upon request. If a supplier cannot 
furnish this documentation, the DMERC can deny the claim and 
request an overpayment. 
Concerns About Medicare Payments for Power Wheelchairs 
In calendar year (CY) 2001, Medicare and its beneficiaries paid 
$538 million for all power wheelchairs. Payments for procedure code 
K0011, a standard-weight power wheelchair with programmable control 
parameters, accounted for 95 percent of this total ($513 million). In 
CY 2001, Medicare allowed approximately $5,000 for each K0011 power 
wheelchair. Payments for the K0011 code have been rising 
dramatically, increasing 43 percent from the year 2000 to 2001 alone. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  3  I N T R O D U C T I O N  
In September 2003, CMS and the Office of Inspector General (OIG) 
issued a joint press release that cited a number of fraud cases involving 
power wheelchairs that were not supplied, not medically necessary, or 
both. OIG has also investigated cases where suppliers billed Medicare 
for a K0011 power wheelchair but provided beneficiaries with scooters, 
which are reimbursed at less than half the amount of K0011 power 
wheelchairs. In order to address significant increases in allowances for 
power wheelchairs and indications of improper billing activity, CMS has 
launched a campaign to curb abuse of the Medicare program by 
unscrupulous suppliers of mobility products. Initiatives in this 
campaign include: revising coverage policy for power wheelchairs and 
scooters to ensure that national policy accurately defines the conditions 
under which Medicare will cover mobility products; adopting a 
consistent approach to medical review; clarifying physicians 
responsibilities as prescribers of mobility devices; and educating 
beneficiaries about Medicare coverage guidelines. 
METHODOLOGY 
Sample Design 
We focused our review on procedure code K0011, which is a standard-

weight power wheelchair with programmable control parameters for 

speed adjustment, tremor dampening, acceleration control, and braking. 

We extracted all paid claims for procedure code K0011 from CMSs 2001 

National Claims History File. According to this claims data, 99 percent 

of all expenditures for K0011s were for first-month purchases. 

Therefore, our sampling frame of 100,124 claims included only K0011 

power wheelchairs that were purchased by the beneficiary in the first 

month. Claims for rentals were not included. We selected a simple 

random sample of 386 claims from the sampling frame. Using 

information from CMSs beneficiary enrollment database, we then 

removed claims associated with deceased beneficiaries. We also 

removed claims with suppliers or ordering physicians that were under 

investigation by OIGs Office of Investigations. We removed a total of 

86 claims, resulting in a final sample of 300 power wheelchair claims. 

These 300 sample claims represent an estimated $394 million in 

allowances for K0011 power wheelchairs.

Data Collection

Supplier Contacts. We identified suppliers who submitted the sample 

claims and contacted these suppliers using address information from 

OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  4  I N T R O D U C T I O N  
CMSs National Supplier Clearinghouse. We requested that suppliers 
provide us with CMNs and additional documentation in support of 
sample claims. We also requested that suppliers provide delivery 
records for these sample items. 
We made up to three attempts to contact each supplier by overnight 
mail with a signature request. We received responses for 272 of the 300 
claims in our sample. We could not locate suppliers for 17 claims due to 
incorrect address information; therefore, we did not include these claims 
in our analysis of supplier documentation. We did not receive responses 
for 11 claims. For the purposes of our study, we concluded that the 
suppliers for these claims did not have supporting documentation, and 
included the claims in our analysis of missing CMNs and delivery 
documentation. Therefore, a total of 283 claims were used in our 
analysis of CMNs and delivery documentation. 
Physician Contacts.  Using address information collected from suppliers, 
we contacted the ordering physicians for sample claims. We requested 
copies of Medicare beneficiaries medical records in support of sample 
claims for power wheelchairs. Specifically, we requested all 
documentation (including office visit notes, referrals for physical or 
occupational therapists, and hospital admission histories and discharge 
summaries) from the 6-month period prior to and including the date on 
the sample claim. 
Suppliers were able to provide physician address information for 271 
claims. We made up to three written attempts to contact these 
physicians. We did not receive responses for 15 claims and were unable 
to contact ordering physicians for an additional 9 claims due to incorrect 
addresses. We did receive responses for 247 claims; however, 
physicians did not submit the requested information for 35 of these 
claims. For 7 of the 35 claims, the physicians indicated that they never 
ordered the power wheelchairs. These seven claims have been referred 
to OIGs Office of Investigations for further development. 
Beneficiary Contacts. Using numbers obtained from both suppliers and 
the Internet, we telephoned the beneficiaries for whom sample 
wheelchairs were ordered. We asked beneficiaries how they learned 
about suppliers, whether suppliers provided them with equipment, and 
whether they have used the equipment. We also asked each beneficiary 
specific questions about the equipment provided, such as the brand 
name, model number, and serial number of the item. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  5  I N T R O D U C T I O N  
We completed telephone interviews with 166 of the 300 beneficiaries in 
our sample. Responses from these 166 beneficiaries formed the basis for 
our analysis. We did not project our results to the population. Of the 
134 non-respondents, 69 were beneficiaries for whom we could not find 
telephone numbers, 41 were beneficiaries who could not be reached by 
telephone, and 24 were beneficiaries who refused to participate. 
Coverage Review.  We ultimately forwarded a total of 230 medical 
records received from physicians and/or suppliers to an independent 
medical review contractor. Claims for these 230 medical records 
represent an estimated $303 million in allowances for K0011 power 
wheelchairs. Table 1 below shows the results of our effort to collect 
medical information that could be used in a coverage review. 
Table 1. Data Collection Results: Records for Coverage Review 
Number of Claims 
Claims That Were Sent for Coverage Review  230 
Physician Provided Useable Medical Records  212 
Physician Responded But Did Not Provide Useable Medical 
11 
Records; Supplier Provided Useable Records 
Physician Could Not Be Contacted But Supplier Provided Useable 
2 
Medical Records 
Physician Did Not Respond But Supplier Provided Useable Medical 
5 
Records 
Claims That Were Not Sent for Coverage Review  70 
Supplier Did Not Respond, Could Not Be Contacted, Or Did Not 
29 
Provide Address Information for Physician 
Physician Responded But Did Not Provide Useable Medical 
24 
Records; Supplier Did Not Provide Useable Records 
Physician Could Not Be Contacted And Supplier Did Not Provide 
7 
Useable Medical Records 
Physician Did Not Respond And Supplier Did Not Provide Useable 
10 
Medical Records 
Total Claims in Sample  300 
Source: OEI Analysis of Supplier and Physician Data Collection Results, 2003 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  6  I N T R O D U C T I O N  
The medical review contractor conducted a coverage review of the 
records using a data collection instrument jointly developed by our office 
and the contractor. The coverage review instrument included questions 
regarding the patients diagnosis, physical condition, ability to 
ambulate, and ability to operate a power wheelchair. The reviewer 
determined whether the K0011 power wheelchair met the Medicare 
coverage criteria outlined in the DMERC supplier manuals. For cases 
where the physician reviewer determined that the K0011 power 
wheelchair did not meet the Medicare coverage criteria, the reviewer 
indicated whether another, less expensive, mobility device would have 
been appropriate for the patient, given both the coverage criteria and 
the information in the medical records. The reviewer had the option of 
downcoding to one of the following mobility devices: a K0010 power 
wheelchair, which is a standard-weight power wheelchair without 
programmable controls; a scooter; or a manual wheelchair. It is 
important to note that we did not specifically request records to support 
any item other than the K0011 power wheelchair. Also, we did not 
assess the appropriateness of the Medicare coverage criteria. 
Data Analysis 
We reviewed CMNs for sample claims to determine whether the 
information was complete. We then estimated the proportion of claims 
for power wheelchairs with incomplete CMNs. We also determined 
whether suppliers delivery records for sample wheelchairs included the 
required information. We analyzed beneficiary survey responses to 
determine whether suppliers actually provided equipment to the 
beneficiary and whether beneficiaries used the equipment. We also 
identified the ways in which beneficiaries learned about their suppliers. 
We aggregated data received from the medical review contractor and 
estimated the proportion of sample claims that did not meet Medicares 
coverage criteria for a K0011 power wheelchair. To compute 
inappropriate payments, we totaled the allowances for all claims that 
did not meet Medicares coverage criteria for procedure code K0011. 
However, we used adjusted allowances for cases where beneficiaries did 
not meet the coverage criteria for a K0011 power wheelchair but would 
have qualified for a K0010 power wheelchair, a scooter, or a manual 
wheelchair. We then computed the difference between the original and 
adjusted allowances for these claims. Adjusted allowances were derived 
from the 2001 DME fee schedule ceiling amounts for procedure codes 
K0010, E1230 (scooter), and K0005 (ultra-lightweight manual 
wheelchair). We used procedure code K0005 for the adjusted allowance 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  7  I N T R O D U C T I O N  
because it has the highest reimbursement amount of any manual 
wheelchair and is, therefore, the most conservative figure. 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the President=s Council on Integrity and 
Efficiency. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  8    F I N D I N G S

Most reviewed claims did not meet Medicares  Only a small percentage of 
coverage criteria for a K0011 power wheelchair;  reviewed claims (13 percent) met 
Medicares coverage criteria for a 
however, some claims may have met coverage 
K0011 power wheelchair, as 
criteria for a less expensive mobility device 
illustrated in Chart 1 below. 
Although 31 percent of claims did not meet coverage criteria for any 
mobility device, another 45 percent of claims may have met criteria for 
another, less expensive item. 
CHART 1

Claim Met K0011 
Results of Coverage 
 Criteria 
Review for K0011 
 13% 
Power Wheelchairs, 
 Claim Did Not Meet 
n = 230.
 Criteria for Any 
Could Not  Mobility Device 
Determine if Claim  31% 
Met K0011 Criteria 
11% 
Claim Met Criteria 
for Another 
Mobility Device 
45% 
Source: OEI Analysis of Coverage Review Results, 2003 
Almost one-third of reviewed claims did not meet Medicares coverage 
criteria for any type of wheelchair or scooter. 
A medical review contractor determined that 31 percent of reviewed 
claims did not meet Medicares coverage criteria for either a K0011 
power wheelchair or any other type of wheelchair or scooter. In 
CY 2001, Medicare and its beneficiaries paid an estimated $96 million 
for claims that did not meet Medicares coverage criteria for any type of 
wheelchair or scooter. The estimate does not account for any 
accessories that may have been billed in conjunction with the power 
wheelchairs (e.g., arm rests, leg rests, and cushions). If a power 
wheelchair does not meet Medicares coverage criteria, then any 
associated accessories would not be covered. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  9  F I N D I N G S  
Beneficiaries in all of these cases were able to ambulate, although some 
did so with the assistance of a cane or walker. According to the 
coverage criteria for any type of wheelchair, the patients condition must 
be such that without the use of a wheelchair the patient would 
otherwise be bed or chair confined. Therefore, if beneficiaries are 
ambulatory (i.e., not bed or chair confined), they do not qualify for a 
wheelchair or scooter under Medicares coverage guidelines. Physicians, 
however, may not be familiar with this coverage criterion when ordering 
mobility devices for their patients. Medicares coverage criteria for 
power wheelchairs are outlined only in DMERC supplier manuals, 
which are provided to the suppliers who bill for medical equipment but 
not the physicians who order it. The only document that physicians are 
required to review and complete when ordering a wheelchair is the 
CMN. Coverage guidelines are not listed on the CMN for power 
wheelchairs, nor do any of the medical necessity questions on the CMN 
require physicians to address whether patients are non-ambulatory. 
An additional 45 percent of reviewed claims did not meet Medicares 
coverage criteria for the K0011 power wheelchair but may have met criteria 
for another type of wheelchair or scooter. 
According to the medical review contractor, 45 percent of reviewed 
claims did not meet Medicares coverage criteria for a K0011 power 
wheelchair but may have met criteria for a scooter, K0010 power 
wheelchair, or manual wheelchair. In CY 2001, Medicare and its 
beneficiaries spent an estimated $82 million in excessive payments for 
claims that could have been billed using a code for a less expensive 
mobility device. Physicians may not be aware of the differences in 
coverage criteria among the mobility devices available to Medicare 
beneficiaries. Discrepancies between medical necessity questions on the 
CMN and coverage criteria could also cause confusion about the medical 
conditions for which K0011 power wheelchairs would be most beneficial. 
For example, question 6 in section B of the CMN for power wheelchairs 
allows physicians to attribute an upper extremity weakness to a 
cardiopulmonary disease/condition, whereas the coverage guidelines 
refer only to a neurologic or muscular disease/condition. 
Twenty-three percent of reviewed claims did not meet the coverage 
criteria for a K0011 power wheelchair but would have met the coverage 
criteria for a scooter. The beneficiaries in these cases were non-
ambulatory, unable to self-propel a manual wheelchair, and had 
sufficient trunk stability and transfer ability to safely operate a scooter. 
Their medical conditions did not warrant a higher-level power 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  10  F I N D I N G S  
wheelchair. Some beneficiaries may have received K0011 power 
wheelchairs rather than scooters because their ordering physicians were 
not able to prescribe scooters. A scooter is usually covered only if it is 
ordered by a specialist in physical medicine, orthopedic surgery, 
neurology, or rheumatology; however, there are no such restrictions for 
a K0011 power wheelchair, which costs twice as much as a scooter. 
Guidelines regarding the specialties of physicians who order scooters 
may actually prevent beneficiaries from getting the equipment that best 
suits their needs, and could lead to excessive Medicare payments if 
K0011 power wheelchairs are provided in lieu of scooters. 
For 8 percent of reviewed claims, the beneficiary did not meet 
Medicares coverage criteria for a K0011 power wheelchair but would 
have qualified for a K0010 power wheelchair. In most of these cases, 
the beneficiaries were non-ambulatory with significant trunk instability 
and upper extremity weakness but did not have a medical condition 
that would require programmable controls. Medicare coverage 
requirements do not currently provide any guidance as to the medical 
conditions that might benefit from programmable controls. 
An additional 3 percent of reviewed claims would have met the coverage 
criteria for a manual wheelchair rather than a K0011 power wheelchair. 
For these cases, the medical records usually indicated that the 
beneficiaries were non-ambulatory but had sufficient upper extremity 
strength to operate some type of manual wheelchair. 
Eleven percent of reviewed claims did not meet the coverage guidelines 
for a K0011 power wheelchair but may have met criteria for another 
type of wheelchair or scooter. These claims did not meet coverage 
criteria for a K0011 power wheelchair because the beneficiary did not 
need programmable controls. However, due to scanty medical 
documentation, the reviewer was unable to determine what other 
mobility device may have been appropriate for the beneficiary. 
Only 13 percent of reviewed claims met the coverage criteria for a K0011 
power wheelchair. 
In CY 2001, Medicare paid an estimated $38 million for claims that met 
the coverage criteria for K0011 power wheelchairs. The beneficiaries in 
these cases were clearly non-ambulatory, had upper extremity 
weaknesses, and required programmable controls, usually due to 
contractures, tremors, or spasticity. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  11  F I N D I N G S  
Due to insufficient documentation, the reviewer could not determine 
whether another 11 percent of reviewed claims met the coverage criteria for 
the K0011 power wheelchair. 
Insufficient documentation prevented the medical reviewer from 
determining whether an additional 11 percent of reviewed claims met 
the coverage criteria for K0011 power wheelchairs. In CY 2001, 
Medicare and its beneficiaries paid an estimated $34 million for these 
claims. In half of these cases, the medical record did not provide a clear 
description of the beneficiaries ambulatory or functional status. In 
other cases, it was clear that the beneficiary was bed or chair confined, 
but there was not enough information to determine whether 
programmable controls were necessary. 
For over half of K0011 claims, CMNs and/or  CMNs and/or delivery 
delivery documentation were missing, incomplete,  documentation for 52 percent of 
K0011 power wheelchair claims 
or dated after the date of service.	
were missing, incomplete, or 
dated after the date of service on the claim. Some claims had one or more 
of these documentation problems.  Typically, CMNs are submitted 
electronically to the DMERCs; therefore, original copies of CMNs are not 
reviewed unless DMERCs specifically request this information from the 
supplier on a pre- or post-pay basis. Similarly, suppliers are not required 
to submit proof of delivery with the initial claim for payment, and 
DMERCs only collect delivery documentation as part of a pre- or post-pay 
review. 
Five percent of power wheelchair claims did not have the required 
supporting documentation. 
For 5 percent of K0011 power wheelchair claims, suppliers did not provide 
a CMN and/or proof of delivery. According to DMERC requirements, 
suppliers must maintain copies of signed CMNs and furnish them upon 
request. Suppliers must also maintain documentation showing that items 
were delivered to beneficiaries. If suppliers cannot provide this 
documentation, DMERCs can deny the claims and request overpayments. 
We estimate that Medicare and its beneficiaries paid an additional 
$19 million in CY 2001 for K0011 claims that could not be substantiated 
by either a CMN or delivery documentation. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  12  F I N D I N G S  
Even when suppliers did submit CMNs or proof of delivery, the 
documentation was often incomplete or dated after the date of service. 
Although DMERCs require that all elements contained on CMNs be 
completed, original paper CMNs obtained from suppliers for 20 percent of 
claims had at least one item missing. The suppliers National Supplier 
Clearinghouse number and the suppliers charge for the wheelchair were 
the items most often missing from CMNs. 
In addition, CMNs for 13 percent of claims were dated after the service 
date. Almost one-quarter of these CMNs were dated more than a month 
after the date of service on the sample claim, with three CMNs dated 
almost a year after the date of service. 
Although most suppliers submitted proof that power wheelchairs were 
delivered, delivery documentation supporting 29 percent of claims was 
missing one or more of the required elements. Quantity, serial number, 
and brand name of items delivered were the elements most often missing 
from delivery documents. In addition, delivery documentation for 
5 percent of claims showed that the power wheelchair was delivered to the 
beneficiary after the date of service listed on the Medicare claim.  In one 
case, the wheelchair was delivered 2 months after the supplier billed 
Medicare. 
Most responding beneficiaries reported using their  Sixty-eight percent of 
beneficiaries who responded to 
power wheelchairs at home; other beneficiaries 
our survey (113 of 166) 
either do not use their power wheelchairs or use 
currently use their power
them for outside activities only. 
wheelchairs inside their 
homes.  The wife of one beneficiary explained that the power wheelchair 
is a necessary part of [her husbands] life. Its given him back a sense 
of mobility...It gave him back quality of life. Another beneficiary 
volunteered, Its a wonderful invention, without it I would be crawling 
on the floor. 
Although many beneficiaries offered positive comments about their 
wheelchairs and the sense of freedom they provide, 4 percent of 
respondents said that they have never used their power wheelchairs. 
One of these beneficiaries stated, I dont need it yet...When my doctor 
approved it he said for later use. I am walking with a walker. Two 
other beneficiaries said that they never used their power wheelchairs 
because no one showed them how to use the equipment. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  13  FF II NN DD II NN GG SS  
An additional 12 percent of respondents said that they do not currently 
use their power wheelchairs but have used them in the past. Some of 
these beneficiaries no longer use their wheelchairs because the 
equipment is too big and heavy. One beneficiary stated, It's not the 
chair my doctor said I needed when they brought it out and I told them 
so...The wheelchair is too large and too fast...If I used it in my house I 
would tear up my furniture...I just don't like it. Other beneficiaries do 
not currently use their power wheelchairs due to unresolved 
maintenance problems, such as dead batteries or flat tires. One 
beneficiary said, I havent had my chair since July 2002. The chair was 
picked up to be adjusted. I have contacted [the supplier] many, many 
times asking about my chair...I just keep getting the run around. 
Another beneficiary reported, The tires are flat...This is the second 
time the tires have gone flat...The supplier has been saying for months 
that they would pick up their chair but they have not. 
Another 12 percent of respondents reported that they currently use 
their power wheelchairs outside the home only. According to Section 
1861(n) of the Social Security Act, a wheelchair must be needed for use 
in the home. Almost half of these beneficiaries indicated that they do 
not use their wheelchairs inside because the equipment is too large and 
does not fit in their homes. One respondent noted, My apartment isnt 
big enough. I use it when I go out like for a baby shower or to see my 
grandkids play baseball. Another beneficiary said, I wanted a smaller 
model. 
Many beneficiaries who completed our  Almost one-quarter of beneficiaries 
survey responded to suppliers  who responded to our survey learned 
direct marketing practices.  about their power wheelchair 
suppliers from a television 
commercial. As one beneficiary explained, I saw the commercial. They 
said it is free and I thought why not. They were thrilled, I gave them 
my doctors fax number. I had it in 2 days. However, this same 
beneficiary commented that the wheelchair she received was not what I 
thought they advertised for. Another beneficiary said, I saw it on TV. 
They were advertising. I called the company up. They sent me a video. 
They got in touch with my doctor and he came back and said it was 
approved. The beneficiary also noted, If I knew what it cost I would 
not have gotten it. I would have gotten something cheaper. I had no 
idea how much it cost until I got the Medicare bill. An additional 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  14  FF II NN DD II NN GG SS  
9 percent of respondents chose their suppliers after receiving something 
in the mail. Four percent of respondents obtained their power 
wheelchairs from suppliers who visited their homes. One of these 
beneficiaries commented, the door-to-door sales rep gave me $50 for 
signing up and offered me $50 for referrals. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  15  0E XR EE CC UO TMI MV EE N  SD UA MT MI AO RN Y   
 
A power wheelchair can greatly improve the quality of life for an 
individual who otherwise suffers from limited mobility.  However, our 
coverage review indicates that Medicare and its beneficiaries spent an 
estimated $178 million in 2001 for K0011 power wheelchairs that did 
not meet Medicares coverage criteria.  These inappropriate payments 
waste taxpayer dollars that could otherwise fund appropriate 
equipment for needy Medicare beneficiaries. 
CMS has recognized the dramatic growth in payment for and utilization 
of power wheelchairs and is currently taking steps to address these 
issues as part of its 10-point plan of action to curb power wheelchair 
fraud, waste, and abuse.  In fact, CMS has already begun implementing 
some of the options listed in the following recommendation.  We believe 
that continued attention to Medicare payments for K0011 power 
wheelchairs is warranted. 
We recommend that CMS improve compliance with Medicares coverage 
criteria for K0011 power wheelchairs.  CMS should consider the following 
options in order to improve compliance: 
Require DMERCs to revise the coverage policy for K0011 power wheelchairs 
to include specific information about the medical conditions for which Medicare 
will cover this item.  Our findings show that many beneficiaries did not 
meet coverage criteria for the K0011 power wheelchair but may have 
qualified for a lower-priced power wheelchair, a scooter, or a manual 
wheelchair.  Given that patients frequently received K0011 power 
wheelchairs when their conditions warranted a lower level of 
equipment, CMS should evaluate the medical conditions and functional 
abilities that are associated with different types of mobility aids and 
describe these conditions/abilities in the coverage policies.  This will 
ensure that beneficiaries have access to the equipment that is most 
appropriate for their conditions.  DMERCs should also consider 
removing guidelines regarding the specialties of physicians who order 
scooters.  In addition, DMERCs should require that physicians treat the 
patients for whom they order equipment.   
Require DMERCs to conduct frequent reviews of the K0011 procedure code to 
ensure appropriate payments.  When performing reviews of K0011 claims, 
DMERCs should ensure that suppliers have complete and thorough 
documentation.  DMERCs should also request medical records from 
ordering physicians in addition to supporting documentation from 
suppliers.  DMERCs should also consider routinely contacting 
  OEI-03-02-00600  MEDICARE PAYMENTS FOR POWER WHEELCHAIRS  16  RR EE CC OO MM MM EE NN DD AA TT II OO NN  
beneficiaries during the course of reviews to ensure that the equipment 
provided by suppliers is appropriate for and useful to beneficiaries. 
Educate ordering providers about Medicares coverage criteria for different 
types of assistive devices, including power wheelchairs, manual wheelchairs, 
and scooters. Ordering providers play a key role in determining the 
need for and utilization of equipment billed to Medicare. According to 
the Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, payment may not be made for power wheelchairs unless a 
physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist has conducted a face-to-face examination of the patient and 
written a prescription for the item. CMS relies on the clinical judgment 
of these health care professionals to ensure that Medicare only pays for 
items that are most appropriate for beneficiaries.  However, ordering 
providers may not be aware of Medicares coverage requirements for 
mobility devices. A lack of provider education about Medicares 
coverage criteria for wheelchairs could adversely affect physicians 
ability to make informed decisions about the types of mobility devices 
that are best for their patients, which could ultimately lead to 
inappropriate Medicare payments. 
Educate Medicare beneficiaries about coverage criteria for wheelchairs and 
scooters. Beneficiaries also play a key role in ensuring that Medicare 
does not pay for medically unnecessary or unused items. Beneficiaries 
who are knowledgeable about Medicares coverage guidelines can make 
more informed choices about the assistive devices that would meet both 
their own needs and Medicares coverage requirements. 
Agency Comments 
CMS concurred with our recommendation and agreed with our 
suggestions regarding coverage policy revisions and provider and 
beneficiary education. They also agreed that more frequent reviews of 
the K0011 code will help ensure appropriate payments; however, they 
do not believe that routinely contacting beneficiaries would yield 
meaningful results. CMS confirmed that they have already begun 
implementing many of our report recommendations through their power 
wheelchairs workgroup, which was established to develop a plan of 
action to ensure that payments are only made for power wheelchairs 
that are reasonable and necessary. Specific actions by CMS include: 
requiring DMERCs to develop a complete picture of a patients medical 
condition before making medical review coverage determinations; 
developing a regulation to remove the current requirement that scooters 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  17  R E C O M M E N D A T I O N  
be prescribed only by certain specialists; and developing a regulation 
that requires a face-to-face examination by the treating physician prior 
to ordering a power wheelchair. CMS is also poised to release an 
educational campaign designed to provide both physicians and 
beneficiaries with needed information regarding Medicare and DMERC 
coverage policy. The full text of CMSs comments is presented in 
Appendix B. 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  18    A P P E N D I X   ~   A  
Table 1. Estimates and Confidence Intervals 
Point Estimate  95 % Confidence Interval 
Claims Where No Other Item Would Have Been Appropriate  31.30%  25.31% - 37.30% 
Claims That Did Not Meet K0011 Coverage Criteria But May Have 
44.78%  38.35% - 51.21% 
Met Criteria For Another Item 
Total Medicare Allowances in 2001 for Claims That Did Not Meet 
$95,732,940  $77,333,457 - $114,132,423 
Coverage Criteria for Any Wheelchair or Scooter 
Excessive Medicare Allowances in 2001 for Claims That Did Not 
Meet K0011 Coverage Criteria But May Have Met Criteria for  $82,274,760  $68,472,518 - $96,077,002 
Another Item 
Claims That Did Not Meet K0011 Coverage Criteria But Would Have 
23.04%  17.60% - 28.49% 
Qualified For Scooter 
Claims That Did Not Meet K0011 Coverage Criteria But Would Have 
8.26%  4.70% - 11.82% 
Qualified For K0010 
Claims That Did Not Meet K0011 Coverage Criteria But Would Have 
2.61%  0.55% - 4.67% 
Qualfied For Manual Wheelchair 
Claims That Did Not Meet K0011 Coverage Criteria And Reviewer 
10.87%  6.85% - 14.89% 
Could Not Determine If Another Item Would Have Been Appropriate 
Claims That Met K0011 Coverage Criteria  12.61%  8.32% - 16.90% 
Total Medicare Allowances in 2001 for Claims that Met K0011 
$38,288,606  $25,217,076 - $51,360, 135 
Coverage Criteria 
Claims Where Reviewer Could Not Determine Whether K0011 
11.30%  7.21% - 15.40% 
Coverage Criteria Were Met 
Total Medicare Allowances in 2001 for Claims Where Reviewer 
$34,117,123  $21,722,810 - $46,511,437 
Could Not Determine Whether K0011 Coverage Criteria Were Met 
Claims With Documentation That Was Missing, Incomplete, or Dated 
51.94%  46.12% - 57.76% 
After Date of Service 
Claims Without CMNs or Delivery Documentation  5.30%  2.69% - 7.91% 
Total Medicare Allowances in 2001 for Claims Without CMNs 
$19,141,660  $9,692,065 - $28,591,254 
and/or Proof of Delivery 
Claims With CMNs With At Least One Item Missing  19.63%  14.89% - 24.37% 
Claims With CMNs Dated After Date of Service  12.69%  8.70% - 16.67% 
Claims With CMNs Dated After Date of Service That Were Dated 
23.53%  9.08% - 37.97% 
More Than a Month After Date of Service 
Claims With Delivery Documentation With At Least One Item Missing  29.00%  23.57% - 34.42% 
Claims With Delivery Documentation Dated After Date of Service  4.83%  2.27% - 7.40% 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  19
   A P P E N D I X   ~   B

Comments from the Centers for Medicare & Medicaid Services 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  20
 A P P E N D I X ~ B  
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  21
 A P P E N D I X ~ B  
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  22
   A C K N O W L E D G E M E N T S

This report was prepared under the direction of Robert A. Vito, Regional 
Inspector General for Evaluation and Inspections in the Philadelphia 
Regional Office, and Linda M. Ragone, Deputy Regional Inspector 
General. Other principal Office of Evaluation and Inspections staff who 
contributed include: 
Lauren McNulty, Team Leader 
Jennifer Baraldi, Program Analyst 
Cynthia Hansford, Program Assistant 
Stephanie London, Program Specialist 
OEI-03-02-00600  MEDICARE PAYMENTS F OR POWER WHEELCHAIRS  23