Department of Health & Human Services 

OFFICE OF

INSPECTOR GENERAL

 

Daniel R. Levinson 

Inspector General 

July 2011 

OEI-04-09-00260 

 

MOST POWER WHEELCHAIRS IN 

THE MEDICARE PROGRAM DID 

NOT MEET MEDICAL NECESSITY 

GUIDELINES 
 

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 EXECUTIVE SUMMARY

OBJECTIVES

1. To determine the extent to which standard power wheelchairs and 

complex rehabilitation power wheelchairs provided to Medicare 

beneficiaries during the first half of 2007 were medically necessary 

based on records from suppliers.

2. To determine whether records from physicians who prescribed 

power wheelchairs supported the medical necessity of power 

wheelchairs as documented by suppliers.

BACKGROUND

From 1999 to 2003, Medicare payments for power wheelchairs increased 

approximately 350 percent, from $259 million to $1.2 billion annually, 

raising concerns about inappropriate Medicare payments. In response, 

in 2005 and 2006 the Centers for Medicare & Medicaid Services (CMS) 

revised its policies related to power wheelchair coverage and coding. 

After these changes, Medicare’s annual payments for power wheelchairs 

decreased to a relative low of $658 million in 2007. However, 

expenditures rose to $779 million in 2008 and $723 million in 2009.

Beneficiaries are eligible to receive power wheelchairs under Medicare 

Part B coverage of durable medical equipment (DME). Beneficiaries 

who are prescribed power wheelchairs receive them from suppliers, 

which bill Medicare for reimbursement. Before providing a power 

wheelchair, a supplier receives from a prescribing physician a 

prescription for the power wheelchair and documentation from the 

beneficiary’s medical record to support the medical necessity of a power 

wheelchair.

We selected a sample of 375 claims for standard and complex 

rehabilitation power wheelchairs supplied to beneficiaries in the first 

half of 2007 and conducted a medical record review. Based on suppliers’ 

records, reviewers determined whether each claim was medically 

necessary and supported by sufficient documentation. They also 

reviewed records from prescribing physicians. For claims without errors 

based on suppliers’ records, reviewers determined whether the 

prescribing physicians’ records supported the suppliers’ power 

wheelchair claims. 
 

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EXECUTIVE SUMMARY

FINDINGS

Sixty-one percent of power wheelchairs provided to Medicare 

beneficiaries in the first half of 2007 were medically unnecessary or 

had claims that lacked sufficient documentation to determine 

medical necessity. Based on records submitted by suppliers that 

provided power wheelchairs, 9 percent of power wheelchairs were

medically unnecessary and another 52 percent had claims that were 

insufficiently documented to determine whether the power wheelchairs 

were medically necessary. Of the $189 million that Medicare allowed 

for power wheelchairs provided in the first half of 2007, $95 million was 

for power wheelchairs that were medically unnecessary or had claims 

that were insufficiently documented. Beneficiaries who received 

medically unnecessary power wheelchairs needed a less expensive type 

of equipment or a different type of power wheelchair. For 2 percent of 

claims, a less expensive type of equipment (e.g., a scooter or a manual 

wheelchair) should have been provided. For the remaining 7 percent of 

claims, the beneficiaries should have received a different type of power 

wheelchair than was provided. 

Medical necessity and documentation errors varied by power 

wheelchair type. Claims for standard and complex rehabilitation 

power wheelchairs had similar overall error rates (61 and 56 percent, 

respectively). However, standard power wheelchairs were less likely to 

be medically unnecessary than complex rehabilitation power 

wheelchairs (8 and 24 percent, respectively). Conversely, claims for 

standard power wheelchairs were more likely to have insufficient 

documentation than claims for complex rehabilitation power 

wheelchairs (53 and 32 percent, respectively). Because standard power 

wheelchairs accounted for most of Medicare’s power wheelchair 

expenditures, errors among claims for such wheelchairs resulted in 

higher inappropriate payments than did errors among claims for 

complex rehabilitation power wheelchairs ($90 million and $5 million, 

respectively).

Prescribing physicians’ records do not support the medical necessity 

of most power wheelchairs. Seventy-eight percent of claims without 

supplier-record errors were not supported by records provided by 

physicians who prescribed the power wheelchairs. That is, while 

suppliers’ records indicated that power wheelchairs were medically 

necessary, physicians’ records indicated that they were medically 

unnecessary, or physicians’ records provided insufficient documentation or 
 

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EXECUTIVE SUMMARY

no documentation of medical necessity. In most cases, physicians’ records 

had insufficient documentation to support the medical necessity of power 

wheelchairs. Less often, physicians’ records contradicted suppliers’ 

records.

RECOMMENDATIONS

Our review found that power wheelchairs paid for by Medicare are not 

always medically necessary and that claims for power wheelchairs 

frequently have insufficient documentation to support medical 

necessity. We found that of the $189 million that Medicare allowed for 

power wheelchairs provided in the first half of 2007, $95 million was for 

power wheelchairs that were medically unnecessary or had claims that 

were insufficiently documented. Although CMS has taken steps since 

2007 to decrease errors among suppliers of power wheelchairs and other 

DME, Medicare has paid significantly more in recent years for power 

wheelchairs than it did in 2007. These increases may indicate that 

CMS continues to pay for power wheelchairs that are not medically 

necessary and/or that have claims that do not meet documentation 

requirements. 

Two previous OIG reports based on the same sample of power 

wheelchairs found problems with coding and with documentation 

requirements. This report shows additional problems with suppliers’ 

compliance with Medicare requirements. Across all three reports, 

80 percent of claims for power wheelchairs supplied to beneficiaries in 

the first half of 2007 did not meet Medicare requirements. Additionally, 

OIG has issued previous reports identifying substantial vulnerabilities 

in the Medicare Durable Medical Equipment, Prosthetics, Orthotics, 

and Supplies (DMEPOS) benefit. 

Based on our findings and prior work, we recommend that CMS:

Enhance reenrollment screening standards for current DMEPOS 

suppliers. Federal regulations place new DMEPOS suppliers at a risk 

level of “high,” whereas currently enrolled DMEPOS suppliers are placed 

at a risk level of “moderate.” We believe that currently enrolled DMEPOS 

suppliers should be subject to the same enrollment screening standards as 

newly enrolling DMEPOS suppliers and should also be placed at the risk 

level of “high.”
 

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EXECUTIVE SUMMARY

Review records from sources in addition to the supplier, such as the 

prescribing physician, to determine whether power wheelchairs are 

medically necessary. CMS should direct its contractors to review records 

from prescribing physicians, in addition to those from suppliers. 

Continue to educate power wheelchair suppliers and prescribing 

physicians to ensure compliance with clinical coverage criteria. In 

2009, CMS began requiring that suppliers meet quality standards to be 

accredited. Additionally, in recent years CMS has developed a variety of 

educational materials for power wheelchair suppliers and prescribing 

physicians. However, our results indicate that CMS should continue to 

educate, and promote collaboration between, suppliers and physicians to 

ensure that beneficiaries receive medically necessary power wheelchairs 

that are appropriate for their mobility needs. We suggest that CMS focus 

its educational efforts for suppliers and prescribing physicians on the 

following topics:

• requirements for determining and documenting the medical 

necessity of a power wheelchair, 

• requirements for determining the most appropriate power 

wheelchair for a beneficiary, and 

• collaboration between supplier and physician to determine the 

most appropriate power wheelchair for a beneficiary. 

Review suppliers of sampled claims we found to be in error.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with the second, third, and fourth recommendations. 

CMS did not concur with the first recommendation. In response to the 

first recommendation, CMS noted that it has in place other tools that 

allow for increased scrutiny of some current suppliers. Based on this 

report’s findings, which reinforce the findings of multiple OIG reports in 

recent years identifying substantial vulnerabilities in the Medicare 

DMEPOS benefit, we maintain that all current DMEPOS suppliers 

should be subject upon reenrollment to the screening standards for the 

risk level of “high.” 
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 TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................ ..... i

INTRODUC TION ............................................ 1 

FINDINGS ................................................. 19

Sixty-one percent of power wheelchairs provided to 

Medicare beneficiaries in the first half of 2007 were medically 

unnecessary or had claims that lacked sufficient documentation

to determine medical necessity ........................... 19

Medical necessity and documentation errors 

varied by power wheelchair type........................... 22

Prescribing physicians’ records do not support the

medical necessity of most power wheelchairs................. 25

 

RECOMMENDATIONS ..................................... 28

Agency Comments and Office of Inspector General Response.... 31

APPENDIXE S ............................................. 32

A: Clinical Coverage Criteria for Selected 

 Power Wheelchairs................................... 32

B: Clinical Coverage Criteria for Selected Power

Wheelchair Power Options and Accessories ............... 36

C: Population and Sample Sizes by Stratum, First Half

 of 2007 ............................................ 39

D: Estimates and Confidence Intervals ..................... 40

E: Agency Comments ................................... 44

ACKNOWLEDGMENTS ..................................... 48
 

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 INTRODUCTION

OBJECTIVES 

1. To determine the extent to which standard power wheelchairs and 

complex rehabilitation power wheelchairs provided to Medicare 

beneficiaries during the first half of 2007 were medically necessary 

based on records from suppliers.

2. To determine whether records from physicians who prescribed 

power wheelchairs supported the medical necessity of power 

wheelchairs as documented by suppliers.

BACKGROUND

From 1999 to 2003, Medicare payments for power wheelchairs increased 

approximately 350 percent, from $259 million to $1.2 billion annually, 

while overall Medicare program expenditures rose 28 percent.1, 2 This 

increase caused concern within the Office of Inspector General (OIG), 

Government Accountability Office (GAO), and Centers for Medicare & 

Medicaid Services (CMS) about inappropriate Medicare payments.3 In 

response, CMS revised in 2005 and 2006 its Medicare policies related to 

power wheelchair coverage and coding.4 After these changes, 

Medicare’s annual payments for power wheelchairs decreased to a 

relative low of $658 million in 2007. However, expenditures rose to 

$779 million in 2008 and $723 million in 2009.

Beneficiaries are eligible to receive power wheelchairs under Medicare 

Part B coverage of durable medical equipment (DME).5 Most 

beneficiaries who require power wheelchairs are unable to walk and 

1 “Medicare payments” refers to the total Medicare-allowed amounts. Medicare pays 

80 percent of the fee schedule amount, and the Medicare beneficiary is responsible for 

paying the remaining 20 percent.

2 71 Fed. Reg. 17021, 17022 (Apr. 5, 2006). 

3 For example, Department of Health & Human Services (HHS) OIG, Medicare Payments 

for Power Wheelchairs, OEI-03-02-00600, April 2004; GAO, CMS’s Program Safeguards Did 

Not Deter Growth in Spending for Power Wheelchairs, GAO-05-43, November 2004; and 

CMS and OIG, New Efforts Aimed at Stopping Abuse of the Power Wheelchair Benefit in 

the Medicare Program, September 9, 2003, accessed at 

http://oig.hhs.gov/publications/docs/press/2003/090903release.pdf on October 25, 2010. 

4 CMS, Pub. No. 11272P, 2006 Fee Schedule Amounts for Power Mobility Devices Have 

Been Refined, November 2006.

5 42 CFR § 410.38.
 

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INTRODUCTION

have severe upper body weakness.6 Beneficiaries who are prescribed 

power wheelchairs by their physicians receive them from DME 

suppliers, which bill Medicare for reimbursement. Prior to January 1, 

2011, the beneficiary was able to choose to rent or purchase the power 

wheelchair.7 Almost all beneficiaries chose to purchase their power 

wheelchairs.8

Power Wheelchair Types

Medicare covers more than 650 models of power wheelchairs.9 Each 

model is assigned to 1 of 42 power wheelchair HCPCS codes.10 The 

HCPCS code assignment is based on the model’s performance, weight 

capacity, seat type, portability, and power seating system capability.11

In the first half of 2007, two types of power wheelchairs—standard and 

complex rehabilitation—accounted for over 80 percent of all Medicare 

expenditures for power wheelchairs.

 

12, 13 These two types are covered 

by Medicare under 27 HCPCS codes that include nearly 400 power 

wheelchair models.14

6 CMS’s Medicare Learning Network, Medicare Coverage of Power Mobility Devices: 

Power Wheelchairs and Power Operated Vehicles, April 2006.

7 Effective for items furnished on or after January 1, 2011, section 3136(a)(2) of the 

Affordable Care Act (ACA) eliminated the lump-sum (up-front) purchase option for standard 

power wheelchairs. Medicare pays for a maximum of 13 continuous months of rental, and 

the supplier must transfer ownership to the beneficiary after the 13th month. For complex 

rehabilitation power wheelchairs, payment can continue to be made on a lump-sum 

purchase basis or monthly rental basis.

8 In the first half of 2007, new power wheelchair purchases accounted for 95 percent of 

Medicare power wheelchair expenditures. OIG analysis of claims from the National Claims 

History file submitted under Healthcare Common Procedure Coding System (HCPCS) codes 

K0823–K0864 with dates of service from January 1 to June 30, 2007. 

9 Medicare Pricing, Data Analysis, and Coding (PDAC) contractor, Motorized Wheelchair 

Product Classification List, April 21, 2010. 

10 Power wheelchair HCPCS codes are K0813–K0864. Within that range, Medicare has 

not assigned power wheelchairs to the HCPCS codes K0817–K0819, K0832–K0834, and 

K0844–K0847.

11 Medicare PDAC contractor, Power Mobility Device Coding Guidelines. Accessed at 

https://www.dmepdac.com/resources/articles/2006/08_14_06.pdf on September 20, 2010. 

12 Standard power wheelchairs are HCPCS code K0823, and complex rehabilitation 

power wheelchairs are HCPCS codes K0835–K0843 and K0848–K0864. DMEPOS Supplier 

Quality Standards, August 2007, p. 11. The remaining 20 percent of claims were for power 

wheelchairs with characteristics similar to those of standard power wheelchairs; these 

power wheelchairs are reimbursed under HCPCS codes K0813–K0831. 

13 OIG analysis of claims from the National Claims History file submitted under HCPCS 

codes K0823 and K0835–K0864 with dates of service from January 1 to June 30, 2007, 

processed as of June 30, 2007. 

14 PDAC contractor, Motorized Wheelchair Product Classification List, April 21, 2010. 
 

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INTRODUCTION

Standard power wheelchairs. Standard power wheelchairs are designed 

for daily use to provide basic mobility for persons weighing less than 

300 pounds. Accessories, such as armrests and oxygen tank carriers, 

may be added to standard power wheelchairs.15 

In the first half of 2007, standard power wheelchairs accounted for 

nearly three-quarters of Medicare’s claims and expenditures for power 

wheelchairs.16 Medicare covers 100 models of standard power 

wheelchairs under HCPCS code K0823.17 

Medicare’s 2007 fee schedule amount for standard power wheelchairs 

was $4,024.18 In January 2009, the fee schedule amount for such 

wheelchairs was reduced by 9.5 percent, to $3,641.19

Complex rehabilitation power wheelchairs. To receive a complex 

rehabilitation power wheelchair, a beneficiary must meet criteria 

beyond those required to receive a standard power wheelchair. The 

beneficiary’s mobility limitation must either (1) require one or more 

power options or a ventilator; or (2) result from a neurological condition, 

muscle disease, or skeletal deformity.20 The beneficiary must also have 

received a specialty evaluation, and the beneficiary’s weight should be 

15 In the first half of 2007, standard power wheelchairs were supplied with an average of 

two accessories. Medicare’s average allowed amount for an accessory for a standard power 

wheelchair was $234. OIG analysis of claims from the National Claims History file 

submitted under HCPCS code K0823 with dates of service from January 1 to June 30, 2007, 

processed as of June 30, 2007. 

16 OIG analysis of claims from the National Claims History file submitted under HCPCS 

code K0823 with dates of service from January 1 to June 30, 2007, processed as of June 30, 

2007. 

17 Medicare PDAC contractor, Motorized Wheelchair Product Classification List, loc. cit.

18 DME, Prosthetics, Orthotics, and Supplies (DMEPOS) 2007 Fee Schedule. Accessed 

at http://www.cms.gov/DMEPOSFeeSched/LSDMEPOSFEE/list.asp#TopOfPage on June 1, 

2011.

19 In July 2008, the Medicare Improvements for Beneficiaries and Providers Act of 2008 

(MIPPA) delayed and reformed the Medicare DMEPOS Competitive Bidding Program. To 

offset the cost savings lost by this delay, MIPPA reduced fee schedule amounts in 

January 2009 by 9.5 percent. In January 2011, Medicare began to use prices from the 

Round 1 Rebid of the Competitive Bidding Program in nine geographical areas. Under the 

program, Medicare and its beneficiaries will pay between $2,276 and $2,716 for standard 

power wheelchairs.

20 Local Coverage Determination (LCD) for Power Mobility Devices, “Indications and 

Limitations of Coverage and/or Medical Necessity.” Also, see Medicare’s LCD for 

Wheelchair Options/Accessories. 
 

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INTRODUCTION

less than or equal to the weight capacity of the power wheelchair type 

that is provided.21

In the first half of 2007, complex rehabilitation power wheelchairs 

accounted for less than 7 percent of Medicare power wheelchair claims 

and expenditures.

 

22, 23 Medicare covers 299 models of complex 

rehabilitation power wheelchairs under 26 HCPCS codes.24

As with standard power wheelchairs, a variety of accessories may be 

added to complex rehabilitation power wheelchairs. Unlike standard 

power wheelchairs, complex rehabilitation power wheelchairs can also 

be upgraded with power options (e.g., a power seating system) or many 

other electronic features (e.g., a device to enable the user to control the 

chair by sipping and puffing through a straw).

 

25

Medicare’s 2007 fee schedule amounts for complex rehabilitation power 

wheelchairs ranged from $4,132 to $11,965.

 We refer collectively to 

the power options and other electronic features that can be added to 

complex rehabilitation power wheelchairs as “power options.” 

26 In January 2009, fee 

schedule amounts for complex rehabilitation power wheelchairs were 

reduced by 9.5 percent, to a range of $3,739 to $10,828.27

Medicare Clinical Coverage Criteria for Power Wheelchairs, Power Options, 

and Accessories 

 

General provisions of the Social Security Act (the Act) govern Medicare 

reimbursement for all items and services, including power wheelchairs.

21 LCD for Power Mobility Devices, “Indications and Limitations of Coverage and/or 

Medical Necessity.” 

22 Complex rehabilitation power wheelchairs include HCPCS codes K0835–K0864. 

23 OIG analysis of claims from National Claims History file submitted under HCPCS 

codes K0835–K0864 with dates of service from January 1 to June 30, 2007, processed as of 

June 30, 2007.

24 Medicare PDAC contractor, Motorized Wheelchair Product Classification List, loc. cit.

25 In the first half of 2007, complex rehabilitation power wheelchairs were supplied with 

an average of five power options and/or accessories. Medicare’s average allowed amount for 

a power option or an accessory supplied with a complex rehabilitation power wheelchair 

was $995. OIG analysis of claims from National Claims History file associated with claims 

submitted under HCPCS codes K0835–K0864 with dates of service from January 1 to 

June 30, 2007, processed as of June 30, 2007. 

26 DMEPOS 2007 Fee Schedule ceiling amounts for HCPCS codes K0835 and K0864.

27 In July 2008, MIPPA delayed and reformed the Medicare DMEPOS Competitive 

Bidding Program. To offset the cost savings lost by this delay, MIPPA reduced fee schedule 

amounts in January 2009 by 9.5 percent. MIPPA also exempted complex rehabilitation 

power wheelchairs from the Competitive Bidding Program.
 

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INTRODUCTION

• Section 1862(a)(1)(A) of the Act states that no payment may be made 

for items or services that “are not reasonable and necessary for the 

diagnosis or treatment of illness or injury or to improve the 

functioning of a malformed body member.”28

• Section 1833(e) of the Act requires that suppliers furnish “such 

information as may be necessary in order to determine the amounts 

due” to receive Medicare payment.29

Coverage criteria for power wheelchairs are found in Medicare’s 

National Coverage Determination (NCD) for Mobility-Assistive 

Equipment and LCD for Power Mobility Devices. 30 The NCD 

establishes an approach to coverage that requires a sequential analysis 

of a patient’s mobility status, and the LCD integrates this approach to 

establish a comprehensive standard for the provision of power 

wheelchairs. Relevant sections of the NCD and LCD are included in 

Appendix A. 

Until 2005, CMS used a “bed- or chair-confined” standard to establish 

the medical necessity of a power wheelchair. 31 In 2005, CMS published 

revised criteria that more closely tied Medicare coverage for a power 

wheelchair to a beneficiary’s medical condition and ability to function in 

the home. According to the revised coverage criteria, power wheelchairs 

and other mobility-assistive equipment are medically necessary for 

beneficiaries who have mobility limitations that impair their 

participation in mobility-related activities of daily living, such as using 

the toilet, feeding, dressing, and bathing. A power wheelchair is

28 42 CFR § 411.15(k)(1).

29 42 CFR § 424.5(a)(6). This requirement applies to the entity that submits the claim 

for payment to Medicare; in the case of power wheelchairs, the supplier submits the claim. 

30 Medicare National Coverage Determinations Manual, § 280.3. Mobility-assistive 

equipment is a DME category that includes canes, crutches, walkers, manual wheelchairs, 

scooters, and power wheelchairs. The term “power mobility devices” includes poweroperated vehicles (scooters) and power wheelchairs. 

The LCD for Power Mobility Devices includes detail beyond that in the NCD regarding 

nonclinical coverage criteria (i.e., documentation) and clinical coverage criteria for power 

wheelchairs. Medicare’s four DME Medicare Administrative Contractors (MAC) have 

adopted the same LCD for Power Mobility Devices. The relevant LCD policy numbers are 

L21271, L23613, L23598, and L27239. 

31 CMS’s Medicare Learning Network, loc. cit. Until 2005, a power wheelchair was 

covered when the beneficiary’s condition was such that, without the use of a wheelchair, the 

beneficiary would otherwise be bed- or chair-confined; a wheelchair was medically

necessary and the beneficiary was unable to operate a wheelchair manually; and the 

beneficiary was capable of safely operating the controls for the power wheelchair. 
 

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INTRODUCTION

medically necessary when a beneficiary’s mobility deficit cannot be 

addressed using other types of mobility-assistive equipment, such as a 

cane, manual wheelchair, or scooter. Additional criteria for a power 

wheelchair include:

• a beneficiary or a beneficiary’s caregiver must be willing and able, 

physically and mentally, to operate a power wheelchair; and

• a beneficiary’s home must provide adequate access between rooms, 

maneuvering space, and surfaces for the operation of the power 

wheelchair that is provided.

To qualify for specific types of power wheelchairs, a beneficiary must 

meet additional criteria.32 For example, his or her weight must be less 

than or equal to the capacity of the power wheelchair. Additionally, 

some power wheelchairs are medically necessary only when a 

beneficiary has a certain diagnosis. 

Power options and accessories are covered only if the beneficiary has a 

power wheelchair that meets Medicare coverage criteria.33 Medicare’s 

LCD for Wheelchair Options/Accessories specifies additional coverage 

criteria. See Appendix B for criteria for some power options and 

accessories. 

Prescribing and Providing Power Wheelchairs to Medicare Beneficiaries 

A Medicare beneficiary may be prescribed a power wheelchair by a 

physician after the physician conducts a face-to-face examination. 

During this examination, the physician assesses the beneficiary’s 

medical condition and mobility needs and determines whether a power 

wheelchair is medically necessary as part of an overall treatment 

plan.34 CMS requires that a beneficiary who needs a complex 

rehabilitation power wheelchair receive an additional specialty 

evaluation, which must be performed by a medical professional with 

32 These are detailed in the LCD for Power Mobility Devices. 

33 Medicare’s LCD for Wheelchair Options/Accessories. 

34 42 CFR § 410.38(c)(2)(i). CMS has stated: “We believe the beneficiary’s physician or 

treating practitioner is in the best position to evaluate and document the beneficiary’s 

clinical condition and PMD [power mobility device] medical needs, and good medical 

practice requires that this evaluation be adequately documented.” 71 Fed. Reg. 17024 

(Apr. 5, 2006). 
 

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experience in evaluations for rehabilitation power wheelchairs, such as 

an occupational or physical therapist.35

From a prescribing physician, a supplier receives a prescription for a 

power wheelchair and documentation from the beneficiary’s medical 

record to support the medical necessity of the power wheelchair.

 

36 

Supporting medical documentation includes the report from the face-toface examination and any other parts of the beneficiary’s medical record 

needed to support the medical necessity of the power wheelchair. For 

complex rehabilitation power wheelchairs, the specialty evaluation 

report is part of the supporting medical documentation. Based on the 

prescription and supporting medical documentation, the supplier 

recommends a type of power wheelchair for the beneficiary; the type 

must be approved by the prescribing physician.37 The supplier is also 

responsible for assessing the beneficiary’s home environment before or 

during the delivery of the power wheelchair to verify that the 

beneficiary can adequately maneuver the chair in his or her home.38

CMS Activities To Improve Compliance With Medicare Power Wheelchair 

Requirements

 

CMS is responsible for paying Medicare claims and ensuring the 

integrity of those payments. CMS employs contractors that perform 

many functions to prevent, identify, and recover inappropriate Medicare 

payments for power wheelchairs. For example, DME MACs publish a 

variety of educational materials for suppliers and prescribing 

physicians. They also host educational symposia, “ask-the-contractor” 

calls, Web-hosted seminars, and online tutorials (podcasts). The DME 

MACs also publish “Dear Physician” letters for suppliers to educate 

physicians on coverage criteria for specific items, including power 

mobility devices. 

Additionally, MIPPA required all DMEPOS suppliers to meet quality 

standards for Medicare accreditation by September 30, 2009. The 

standards that CMS developed include business standards in areas such 

as suppliers’ administration, consumer services, and product safety. 

Suppliers must also meet product-specific standards. For example, 

35 LCD for Power Mobility Devices. The specialty evaluation report must document the 

medical necessity for the power wheelchair and each recommended option and accessory. 

36 LCD for Power Mobility Devices, “Documentation Requirements.”

37 Ibid.

38 Ibid.
 

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power wheelchair suppliers are required to “provide the beneficiary with 

appropriate equipment for trial and simulation, when necessary” and 

“verify that seating, positioning and specialty assistive technology have 

been evaluated and documented in the beneficiary’s record.”39, 40 

In February 2011, CMS published a final rule implementing provisions 

of ACA that establish procedures under which screening is conducted 

for providers of medical or other services and suppliers in the Medicare 

program.41 Section 1866(j)(2)(B) of the Act requires the Secretary to 

determine the level of screening to be conducted according to the risk of 

fraud, waste, and abuse with respect to the category of provider or 

supplier. CMS created three levels of risk: limited, moderate, and 

high.42 New DMEPOS suppliers were placed at the “high” risk level, 

while currently enrolled DMEPOS suppliers were placed at the 

“moderate” risk level.43

Medical Record Review by Medicare Contractors

Medicare contractors are required to analyze providers’ and suppliers’ 

compliance with Medicare coverage and coding requirements and to 

take corrective action when instances of noncompliance are identified.44 

As part of this, contractors conduct medical reviews of supporting 

documentation for selected claims to determine whether the claims met 

Medicare coverage criteria.45 Every year, the Medicare Comprehensive 

Error Rate Testing (CERT) contractor reviews medical records to 

39 DMEPOS Supplier Quality Standards. Accessed at 

http://www.cms.hhs.gov/MedicareProviderSupEnroll/Downloads/DMEPOSAccreditationSta

ndards.pdf on December 5, 2008.

40 The requirement pertaining to equipment trials applies only to suppliers of complex 

rehabilitation power wheelchairs. 

41 76 Fed. Reg. 5864, 5865 (Feb. 2, 2011). 

42 Screening will include a licensure check, which may include checks across State lines, 

and the screening may also include (1) a fingerprint-based criminal background check; 

(2) unscheduled or unannounced site visits, including preenrollment site visits; (3) database 

checks, including checks across State lines; and other screening as the Secretary determines 

appropriate.

43 To maintain Medicare billing privileges, a DMEPOS supplier must resubmit and 

recertify the accuracy of its enrollment information every 3 years. 42 CFR § 424.57(e).

44 CMS’s Medicare Program Integrity Manual, Pub. No. 100-08, ch. 3, § 3.1.

45 Contractors select claims for medical review by first selecting areas for review (e.g., 

providers, services) that are deemed high priority. Using claims data, the contractor 

determines the degree to which a potential error is widespread and meets established 

deviation indicators. If no legitimate explanation exists, the contractor selects a sample of 

cases representative of the universe in which the problem is occurring. CMS’s Medicare 

Program Integrity Manual, Pub. No. 100-08, ch. 3, § 3.2.
 

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INTRODUCTION

establish a national paid-claims error rate for the Medicare 

Fee-for-Service program. DME MACs and other benefit integrity 

contractors use error rates produced by the CERT contractor to target 

their efforts to prevent improper payments.46

CMS directs its contractors to collect medical records from the provider 

or supplier submitting the claim. However, CMS does not require 

contractors to review records from the prescribing physician or any 

other providers that rendered care to the beneficiary. If the contractors 

choose to collect records from these other providers, they must first or 

simultaneously solicit the same information from the provider or 

supplier submitting the claim.47

In 2006, OIG found that the CERT review of DME claims relied 

primarily on supplier records.

 

48 When additional medical records from 

physicians and other health care providers were reviewed, OIG found a 

large number of additional errors, including claims for medically 

unnecessary power wheelchairs, that were not identified by CMS’s 

CERT contractor. OIG made a series of recommendations, among them 

that the CERT contractor review all medical records (including the 

records of prescribing physicians) necessary to determine compliance 

with applicable medical necessity requirements. CMS concurred, and in 

2007, its CERT contractor began asking physicians, in addition to 

suppliers, for supporting information.49

Prior Office of Inspector General Work 

 

OIG has issued multiple reports in recent years identifying substantial 

vulnerabilities among Medicare power wheelchair claims and other 

DMEPOS claims. In April 2004, OIG reported on the medical necessity 

of power wheelchairs provided to Medicare beneficiaries during 2001.50

46 CMS’s Medicare Program Integrity Manual, Pub. No. 100-08, ch. 1, § 1.3.1.

 

47 CMS’s Medicare Program Integrity Manual, Pub. No. 100-08, ch. 3, § 3.4.1.2.

48 HHS OIG, Medical Review of Claims for the Fiscal Year 2006 Comprehensive Error 

Rate Testing Program, A-01-07-00508, August 2008. 

49 OIG also recommended that CMS establish a written policy to address the appropriate 

use of clinical inference (i.e., a clinician’s interpretation of the claim’s appropriateness based 

on the medical record, considering the full scope of the beneficiary’s circumstances). The 

primary modification resulting from CMS’s concurrence with the recommendation was to 

require the CERT medical reviewers to strictly follow the documentation requirements 

outlined in the Medicare regulation, statute and policy, including LCDs, rather than 

allowing for clinical review judgment based on billing history and other available 

information.

50 HHS OIG, Medicare Payments for Power Wheelchairs, OEI-03-02-00600, April 2004. 
 

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INTRODUCTION

In that report, OIG found that only 13 percent of claims met Medicare’s 

coverage criteria. After CMS revised in 2005 and 2006 its policies 

related to power wheelchair coverage and coding, OIG began a series of 

reports on Medicare payments for power wheelchairs provided during 

the first half of 2007. 

Since 2009, OIG has issued two reports that assessed compliance with 

different Medicare requirements for power wheelchairs. Both reports 

are based on the same sample (of standard power wheelchairs and 

complex rehabilitation power wheelchairs supplied to Medicare 

beneficiaries in the first half of 2007) used in this report.51 In the first 

report, OIG found that 8 percent of claims for standard and complex 

rehabilitation power wheelchairs from the first half of 2007 were 

miscoded.52 OIG reviewed supplier-submitted manufacturer invoices 

for power wheelchairs and determined whether claims were miscoded 

(i.e., whether the HCPCS code that the supplier used to bill Medicare 

matched the model information on the invoice). In the second report, 

OIG found that 60 percent of claims for standard and complex 

rehabilitation power wheelchairs did not meet Medicare documentation 

requirements during the first half of 2007.53

Further, OIG issued multiple reports between 2005 and 2009 

identifying substantial vulnerabilities in the Medicare DMEPOS 

 OIG determined the extent 

to which suppliers submitted documents that included all required 

information and whether suppliers received the documents from 

prescribing physicians within required timeframes. 

51 Additionally, OIG issued a report on the power wheelchair fee schedule amounts in the 

Medicare program. HHS OIG, Power Wheelchairs in the Medicare Program: Supplier 

Acquisition Costs and Services, OEI-04-07-00400, August 2009.

52 HHS OIG, Miscoded Claims for Power Wheelchairs in the Medicare Program, 

OEI-04-07-00403, July 2009. Power wheelchairs are assigned HCPCS codes based on the 

manufacturers’ model information. Miscoded claims were defined as those for which the 

suppliers billed Medicare using HCPCS codes that did not match the model information on 

the invoices for power wheelchairs supplied to beneficiaries. 

53 HHS OIG, Medicare Power Wheelchair Claims Frequently Did Not Meet 

Documentation Requirements, OEI-04-07-00401, December 2009. The December 2009 

report did not determine whether the required documents were sufficient to support the 

medical necessity of the power wheelchairs or whether the power wheelchairs were 

medically necessary because this review used a medical record review to address those 

questions. 
 

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INTRODUCTION

benefit.54 These problems include deficiencies in enrollment safeguards, 

excessive payments, inappropriate payments, and issues with provider 

appeals. For example, when OIG conducted unannounced site visits to 

1,581 DME suppliers in South Florida in late 2006, nearly a third either 

did not maintain physical facilities or were not open and staffed. OIG 

has made a variety of recommendations to CMS to address these 

vulnerabilities, including strengthening the supplier enrollment 

process. CMS has implemented many of these recommended changes; 

however, OIG continues to find significant vulnerabilities.

Based on joint investigations by the Department of Justice (DOJ), CMS, 

and OIG, in recent years numerous DMEPOS suppliers have been 

charged with and convicted of defrauding the Medicare program, and 

many have had their Medicare billing privileges revoked based on OIG 

work. Examples include the 20 DME company owners and marketers, 

most of them in the Los Angeles area, who were charged in 2009 with 

allegedly billing Medicare for more than $26 million in fraudulent 

claims for power wheelchairs, orthotics, and hospital beds.55 Effective 

January 1, 2007, CMS revoked the billing privileges of 491 South 

Florida DME suppliers that did not maintain appropriate physical 

facilities or had facilities that were not accessible to beneficiaries during 

reasonable or posted business hours on at least two visits.56 

METHODOLOGY

Scope

This evaluation focused on standard and complex rehabilitation power 

wheelchairs provided to Medicare beneficiaries during the first half of 

2007. Our population consisted of claims for new, nonrental power 

wheelchairs from CMS’s National Claims History DME Standard 

54 For example, HHS OIG, South Florida Suppliers’ Compliance With Medicare 

Standards: Results From Unannounced Visits, OEI-03-07-00150, March 2007; HHS OIG, 

Los Angeles County Suppliers’ Compliance with Medicare Standards: Results From 

Unannounced Visits, OEI-09-07-00550, February 2008; HHS OIG, South Florida Medical 

Equipment Suppliers: Results of Appeals, OEI-03-07-00540, October 2008; HHS OIG, 

Power Wheelchairs in the Medicare Program: Supplier Acquisition Costs and Services,

OEI-04-07-00400, August 2009.

55 DOJ, Office of Public Affairs, Los Angeles Medicare Fraud Strike Force Charges 20 in 

Health Care Fraud Cases Involving Durable Medical Equipment. Accessed at 

http://www.justice.gov/opa/pr/2009/October/09-crm-1131.html on February 23, 2011.

56 HHS OIG, South Florida Medical Equipment Suppliers: Results of Appeals, 

OEI-03-07-00540, October 2008.
 

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INTRODUCTION

Analytical File with dates of service in the first half of 2007.57 We based 

this evaluation on data from a medical record review of a random 

sample of power wheelchair claims. 

Based on suppliers’ records, we determined whether power wheelchairs 

met clinical coverage criteria. We also reviewed the medical necessity of 

power options and accessories supplied with complex rehabilitation 

power wheelchairs. We did not review accessories supplied with 

standard power wheelchairs because beneficiaries who received such 

wheelchairs needed fewer, less expensive accessories. We did not 

determine whether sampled power wheelchair claims were coded 

correctly or met nonclinical documentation requirements; in separate 

reports, OIG has noted the rates of miscoding and documentation error 

in power wheelchair claims.58 We also reviewed prescribing physicians’ 

records. However, we did not determine whether claims met clinical 

coverage criteria based on physicians’ records. 

Sample Selection

We removed from our population claims from suppliers or prescribing 

physicians under OIG investigation and claims from suppliers that were 

inactive or whose billing privileges had been revoked since the time they 

submitted the claims.59, 60 We grouped the resulting population into 

three strata: 

57 We analyzed claims that CMS processed as of June 30, 2007. That claims file is 

estimated to be 79 percent complete; that is, it included 79 percent of all claims for power 

wheelchairs provided during the first half of 2007. 

58 Miscoded Claims for Power Wheelchairs in the Medicare Program, loc. cit., and

Medicare Power Wheelchair Claims Frequently Did Not Meet Documentation Requirement, 

loc. cit. 

59 Pursuant to 42 CFR § 424.520(a), to maintain Medicare billing privileges after initial 

enrollment, suppliers must comply with Medicare regulations and relevant Federal and 

State requirements. Pursuant to 42 CFR § 424.535, Medicare may revoke a supplier’s 

billing privileges because of a felony, noncompliance with enrollment requirements, etc. 

Pursuant to 42 CFR § 424.540, Medicare also may deactivate a supplier’s billing privileges 

when the supplier does not submit a claim for a full year or when the supplier fails to report 

a change in the information provided on the enrollment application, such as a change in 

practice location or ownership. 

60 After we removed these claims—3,430 claims for standard power wheelchairs and 

301 claims for complex rehabilitation power wheelchairs—our population consisted of 

43,133 claims for standard power wheelchairs, or 93 percent of such claims; and 

3,001 claims for complex rehabilitation power wheelchairs, or 91 percent of such claims.
 

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INTRODUCTION

1. standard power wheelchair claims submitted by low-volume 

suppliers (i.e., those that submitted fewer than 10 standard power 

wheelchair claims in the first half of 2007), 61 

2. standard power wheelchair claims submitted by high-volume 

suppliers (i.e., those that submitted 10 or more standard power 

wheelchair claims in the first half of 2007), and 

3. complex rehabilitation power wheelchair claims.

We sampled 375 claims by selecting simple random samples of 

125 claims from each stratum.62 Appendix C provides the number of 

claims, amount of Medicare expenditures, and number of suppliers for 

the population and sample, by stratum. 

We also identified power options and accessories supplied with complex 

rehabilitation power wheelchairs in our sample. Claims for power 

options and accessories (1) had HCPCS codes listed in Medicare’s LCD 

for Wheelchair Options/Accessories and (2) shared the same unique 

control number assigned by the DME MAC as a sampled claim for a 

complex rehabilitation power wheelchair.

Data Collection 

We requested beneficiary records from the supplier and prescribing 

physician to support each sampled claim. 

Supplier records. We obtained the supplier addresses from the 

National Supplier Clearinghouse data file. To increase our response 

rate, we sent an initial request and, as needed, sent at least two 

followup letters and contacted the supplier by phone. We received or 

classified as errors 364 of the 375 power wheelchair claims, a 

97-percent response rate. We received supplier records for 

363 claims. We classified the single remaining claim as an error 

because the supplier received but did not respond to our third request 

letter, which was sent via certified mail. In our analysis, we 

considered this claim to be undocumented. We did not include the 

61 We divided the standard power wheelchair population by supplier volume based on the 

distribution of suppliers and claims. For example, 25 percent of suppliers received 

Medicare reimbursement for 10 or more standard power wheelchair claims during the first 

half of 2007, and these claims accounted for 83 percent of all standard power wheelchair 

claims. High-volume suppliers had an average of 50 standard power wheelchair claims, 

while low-volume suppliers had an average of 3 such claims. 

62 All evaluations in the current series of OIG power wheelchair reports, described 

earlier in the report, use this sample methodology. 
 

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INTRODUCTION

remaining 11 claims in our analysis because we could not obtain 

current addresses for the suppliers of 10 claims and the supplier’s 

record for 1 claim was in another language.63 

Prescribing physician records

We used a medical review contractor to collect medical records from 

prescribing physicians. The contractor sent a request and, as needed, at 

least two followup letters and contacted the physician by phone to 

increase the response rate. We received or classified as errors 360 of the 

375 power wheelchair claims, a 96-percent response rate. We received 

prescribing physician records for 322 claims. We classified the 

remaining 38 claims as errors, either because the physician received but 

did not respond to our third request letter (sent via certified mail) or 

because the documentation that the physician produced did not contain 

any information relevant to our sampled claim. In our analysis, we 

considered these claims to be undocumented. We did not include the

remaining 15 claims in our analysis because we could not obtain current 

addresses for the physicians. 

. We obtained the names and addresses of 

physicians who prescribed the power wheelchairs in our sample from 

suppliers. When suppliers did not provide this information, we obtained 

it from either the Unique Physician Identification Number Directory or 

the National Provider Identifier Directory. We requested from the 

prescribing physician all documentation from the beneficiary’s medical 

record, including office visit notes, referrals, and hospital admission 

histories and discharge summaries, during the 12 months prior to the 

date the beneficiary received the power wheelchair. 

Medical Record Review

We used a contractor to conduct a medical record review of the claims in 

our sample and the power options and accessories supplied with the 

complex rehabilitation power wheelchair claims in our sample. For 

each claim, the supplier’s record and the prescribing physician’s record 

were reviewed by a licensed clinician with experience in establishing 

medical necessity for power wheelchairs. The reviewers completed a 

standardized review instrument twice for each claim in the sample: 

once based on a review of the supplier’s record and once based on a 

review of the physician’s record. 

63 We referred to CMS the suppliers that did not respond to our request or for which we 

were unable to locate current addresses. In addition, OIG is considering these suppliers for 

investigation.
 

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INTRODUCTION

The reviewers determined whether claims met Medicare coverage 

criteria from the NCD for Mobility-Assistive Equipment and LCD for 

Power Mobility Devices. They determined whether the power 

wheelchairs were medically necessary and, if not, which other type of 

mobility-assistive equipment (e.g., cane, manual wheelchair, or scooter) 

or other power wheelchair corresponding to a different HCPCS code 

would have been medically necessary, if any. The reviewers indicated 

whether the supplier’s record was insufficient to determine whether the 

power wheelchair was medically necessary. They also determined 

whether power options and accessories provided with the complex 

rehabilitation power wheelchairs were medically necessary and had 

claims that were sufficiently documented. 

Analysis

We aggregated data received from the medical review contractor and 

determined the percentage of sampled claims that did not meet 

Medicare coverage criteria based on the supplier’s record.64

We calculated the inappropriate payments for erroneous claims using 

Medicare-allowed amounts from the National Claims History data. See 

Appendix D (Table D-3) for the point estimates and confidence intervals 

for inappropriate payment projections. We calculated partial 

inappropriate payments for cases in which beneficiaries did not meet 

the coverage criteria for the provided power wheelchair but would have 

 We 

identified the percentages of claims for power wheelchairs that were 

medically unnecessary, claims that were insufficiently documented to 

determine the medical necessity of the power wheelchair, and claims 

that were undocumented. We calculated these error rates for the entire 

sample and for the following subgroups: standard power wheelchair 

claims, complex rehabilitation power wheelchair claims, standard power 

wheelchair claims submitted by low-volume suppliers, and standard 

power wheelchair claims submitted by high-volume suppliers. See 

Appendix D (Table D-1) for the point estimates and confidence intervals 

for the projections of these error rates. We also determined whether 

these error rates differed significantly between claims for standard 

power wheelchairs and those for complex rehabilitation power 

wheelchairs. See Appendix D (Table D-2) for the point estimates and 

confidence intervals associated with these statistical comparisons. 

64 As the provider submitting the claim, the supplier must have records to support that 

the claim met coverage criteria. Therefore, error rates are based on suppliers’ records. 
 

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INTRODUCTION

qualified for a manual wheelchair, cane, or walker or for a different 

power wheelchair. We derived the adjusted allowances from the 

2007 DME fee schedule ceiling amounts.

When the beneficiary would have qualified for a manual wheelchair, a 

cane, or a walker, we used the HCPCS codes E1161 for manual 

wheelchairs and E0147 for canes or walkers because these codes had 

the highest fee schedule amounts for those types of mobility-assistive 

equipment and thus yielded the most conservative figures for 

overpayments. When the beneficiary needed a different power 

wheelchair, we used the fee schedule amount for the appropriate power 

wheelchair (using the HCPCS code indicated by the medical record 

reviewer), calculating the loss to the Medicare program as the difference 

between the cost of the two power wheelchairs. (If the beneficiary 

needed a more expensive power wheelchair, we subtracted that 

difference from the amount of total inappropriate payments.) If the 

beneficiary needed a different type of power wheelchair but the reviewer 

could not determine which HCPCS code would have been appropriate, 

we did not consider any portion of the allowed amount to be 

inappropriate. 

We also identified the percentage of power options and accessories that 

were medically unnecessary or insufficiently documented to determine 

medical necessity.65 Finally, we identified the percentage of claims for 

complex rehabilitation power wheelchairs for which at least one power 

option or accessory was medically unnecessary or insufficiently 

documented to determine medical necessity.66

We determined whether the records from prescribing physicians 

supported claims that suppliers submitted. For claims for which the 

suppliers’ records indicated no errors, we determined whether the 

prescribing physicians’ records yielded the same determinations—that 

is, we identified claims that the prescribing physicians’ records 

indicated were for medically unnecessary power wheelchairs, had 

insufficient documentation, or were undocumented. We removed from 

 See Appendix D 

(Table D-4) for the point estimates and confidence intervals for the 

projections of these error rates. 

65 This analysis is based on 556 claims for power options and accessories provided with 

sample complex rehabilitation power wheelchair claims.

66 This analysis is based on the 108 claims for complex rehabilitation power wheelchairs 

supplied with at least one power option or accessory. 
 

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INTRODUCTION

our analysis claims for which the only difference between the suppliers’ 

records and the physicians’ records was that the former contained a 

home assessment report and the latter did not.67

Finally, we calculated the combined error rate across the three OIG 

reports that had each calculated error rates based on the same sample 

of power wheelchairs.

 See Appendix D 

(Table D-5) for the point estimates and confidence intervals for the 

projections of these calculations. 

68

We projected the error rates, total inappropriate payments, and rates of 

inconsistency between supplier and physician records to the populations 

defined by the strata from which we selected sample claims. We used 

SAS and SUDAAN survey data analysis software to project these 

results. Appendix D includes the point estimates and confidence 

intervals for all reported projections.

 We calculated the combined error rate based on 

two sets of claims from the shared sample of 375 claims: (1) the 

339 claims that were reviewed in all three reports and (2) the 

365 claims that were reviewed in at least one of the three reports. See 

Appendix D (Table D-6) for the point estimates and confidence intervals 

for the projections of these error rates.

Limitations

Our results cannot be extrapolated beyond the timeframe of our 

evaluation. We recognize that since the first half of 2007, CMS has 

continued to educate suppliers and prescribing physicians about its 

power wheelchair clinical coverage criteria and has implemented 

additional program integrity safeguards. Additionally, all suppliers 

were required to meet quality standards as of September 30, 2009. 

Although CMS has taken steps since 2007 to decrease errors among 

suppliers of power wheelchairs and other kinds of DME, Medicare has 

67 This analysis is based on 121 claims. There were 140 claims without errors in the 

supplier record. From these, we removed 19 claims for which the only difference between 

the suppliers’ records and the physicians’ records was that the former contained home 

assessment reports and the latter did not. Discrepancies arising because of this difference 

between records are acceptable; the supplier must have the home assessment report on file, 

but the prescribing physician is not explicitly required to have this report. This analysis 

includes only claims for which we either received the supplier record and the physician 

record or did not receive a response from the supplier and considered the claim to be 

undocumented. 

68 The three reports are this report and two others: Miscoded Claims for Power 

Wheelchairs in the Medicare Program, loc. cit.; and Medicare Power Wheelchair Claims 

Frequently Did Not Meet Documentation Requirement, loc. cit. 
 

 

INTRODUCTION 

paid significantly more for power wheelchairs in recent years than it did 

in 2007.69 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors 

General on Integrity and Efficiency. 

69 Medicare and its beneficiaries paid $658 million for power wheelchairs in 2007, 

$779 million in 2008, and $723 million in 2009. 

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 FINDINGS

Based on records submitted by 

Sixty-one percent of power wheelchairs suppliers that provided power 

provided to Medicare beneficiaries in the first wheelchairs, 9 percent of claims 

half of 2007 were medically unnecessary or had were for power wheelchairs that 

claims that lacked sufficient documentation to were medically unnecessary and 

determine medical necessity another 52 percent had insufficient 

documentation to determine 

whether the power wheelchairs 

were medically necessary.70 Because of these errors, these claims 

should not have been paid. However, Medicare and its beneficiaries 

paid $95 million for power wheelchairs provided in the first half of 2007 

that were medically unnecessary, had claims with insufficient 

documentation, or had claims that were undocumented, out of 

$189 million allowed by Medicare. Table 1 presents the percentage of 

claims that had each type of error and the associated Medicare 

payments. 

Table 1: Error Rates for Medicare Power Wheelchairs, First Half of 2007

Type of Error Claim Error 

Rate

Inappropriate 

Payments 

Power Wheelchair Was Medically Unnecessary * 9% $2 million

Beneficiary needed a less expensive type of 

equipment (i.e., not a power wheelchair)

2%

Beneficiary needed a different type of power 

wheelchair

7%

Claim Had Insufficient Documentation 52% $93 million

Claim Was Undocumented * <1% <$1 million

 Total Errors 61% $95 million

* We are unable to reliably project the weighted point estimates for inappropriate payments associated with 

these error rates because of the small number of sample claims in these categories. We did not include the 

95-percent confidence intervals for these estimates in Appendix D. 

Source: OIG medical record review of Medicare power wheelchair claims.

Two previous OIG reports based on the same sample of claims for power 

wheelchairs found problems with coding and documentation 

70 Additionally, less than 1 percent of claims for power wheelchairs were 

“undocumented”—that is, the supplier did not submit any medical records to document the 

claims. Claims that lack documentation to show that the care was reasonable and 

necessary do not meet Medicare coverage criteria.
 

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FINDINGS

requirements.71 Across all three reports, 80 percent of claims for power 

wheelchairs supplied to Medicare beneficiaries in the first half of 

2007 did not meet Medicare requirements.72

Nine percent of power wheelchairs were medically unnecessary 

 In the current report, we 

found that 61 percent of claims were for wheelchairs that were 

medically unnecessary or had insufficient documentation to determine 

medical necessity. In the two previous reports, OIG found that 

8 percent of claims were miscoded and 60 percent did not meet 

documentation requirements; many claims had more than one of these 

error types.

Claims for 9 percent of power wheelchairs provided to Medicare 

beneficiaries in the first half of 2007 were for power wheelchairs that 

were medically unnecessary. Beneficiaries who received power 

wheelchairs that were medically unnecessary needed a less expensive 

type of medical equipment or a different type of power wheelchair. For 

2 percent of power wheelchair claims, a less expensive type of 

equipment (e.g., a manual wheelchair, cane, or walker) would have been 

more appropriate. For another 7 percent of claims, the beneficiaries 

should have received a different type of power wheelchair than was 

provided. The beneficiaries should have received a less expensive power 

wheelchair for 1 percent of all claims. For another 3 percent of claims, 

the beneficiaries needed a more expensive power wheelchair.73

Regardless of whether a more expensive or less expensive power 

wheelchair was needed, Medicare paid for the wrong equipment to meet 

these beneficiaries’ needs. These claims did not meet Medicare clinical 

coverage criteria as stated in the NCD and LCD. Examples of these 

types of inappropriate power wheelchairs from our sample are:

 

• Claim A: The beneficiary received a complex rehabilitation power 

wheelchair for which Medicare allowed $5,081. This type of power 

wheelchair is necessary for beneficiaries with a neurological, 

71 Miscoded Claims for Power Wheelchairs in the Medicare Program, loc. cit., and

Medicare Power Wheelchair Claims Frequently Did Not Meet Documentation Requirement, 

loc. cit. 

72 Based on sample claims that were reviewed in all three reports. We also calculated 

the combined error rate using claims that were reviewed in at least one of the three reports. 

These claims yielded a combined error rate of 79 percent. 

73 For the remaining 3 percent of claims for which the beneficiary should have received a 

different power wheelchair, the reviewer could not determine the specific power wheelchair 

that the beneficiary needed. Therefore, we did not consider any portion of the 

Medicare-allowed amount to be inappropriate. 
 

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FINDINGS

muscular, or skeletal deformity. However, the beneficiary had a 

diagnosis of chronic obstructive pulmonary disease and cardiac 

disease. Therefore, the beneficiary should have received a standard 

power wheelchair for which Medicare would have allowed up to 

$4,024. In this situation, Medicare overpaid by $1,057.

• Claim B: The beneficiary received a complex rehabilitation power 

wheelchair with a weight capacity of 301–450 pounds, for which 

Medicare allowed $6,130. However, the beneficiary weighed 

85 pounds. Therefore, he should have received a complex 

rehabilitation power wheelchair with a weight capacity of less than 

300 pounds for which Medicare would have allowed up to $5,672. In 

this situation, Medicare overpaid by $458. 

• Claim C: The beneficiary received a complex rehabilitation power 

wheelchair with an automotive-style seat for which Medicare 

allowed $4,208. However, she had a neurological diagnosis that 

results in poor sitting balance and a high risk of skin breakdown. 

Therefore, she needed a power wheelchair with a rehabilitation seat 

providing better postural support and skin protection. For such a 

wheelchair, Medicare would have allowed up to $5,672. In this 

situation, Medicare underpaid by $1,464. 

Fifty-two percent of claims for power wheelchairs had insufficient 

documentation to determine medical necessity 

Claims for 52 percent of power wheelchairs provided during the first 

half of 2007 were insufficiently documented. That is, suppliers’ records 

were insufficient to enable reviewers to determine whether these power 

wheelchairs were medically necessary. Inappropriate payments for 

these claims totaled $93 million. 

Suppliers are required to maintain documentation that supports the 

appropriateness of claims they submit for Medicare reimbursement. 

These claims did not contain sufficient documentation to show that they 

met Medicare clinical coverage criteria as stated in the NCD and LCD. 

Examples of sampled claims that did not have sufficient documentation 

are:

• Claim D: The record did not provide sufficient information about the 

beneficiary’s ability to participate in mobility-related activities of daily 

living, ability to use the power wheelchair in her home, or ability to 

use the power wheelchair safely. Additionally, the documentation did 
 

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FIND INGS

not rule out other, less expensive types of mobility-assistive 

equipment.

• Claim E: The record did not explain why the beneficiary needed a 

power wheelchair. The report of the face-to-face examination by the 

prescribing physician documented a diagnosis of osteoporotic hip 

fracture, which is usually reversible following the surgery that the 

beneficiary received. However, the report did not explain how the 

beneficiary’s condition had changed to require a power wheelchair. 

That is, it did not contain sufficient documentation to show that the 

claims met Medicare clinical coverage criteria.

Claims for standard and complex 

Medical necessity and documentation errors rehabilitation power wheelchairs 

varied by power wheelchair type had similar overall error rates. 

However, standard power 

wheelchairs were less likely to be 

medically unnecessary than complex rehabilitation power wheelchairs. 

Conversely, claims for standard power wheelchairs were more likely to 

have insufficient documentation than were claims for complex 

rehabilitation power wheelchairs.74 Because standard power 

wheelchairs accounted for most of Medicare’s power wheelchair 

expenditures, errors among claims for standard power wheelchairs 

resulted in higher inappropriate payments than did errors among 

claims for complex rehabilitation power wheelchairs.75 

74 The differences in error rates between the two power wheelchair types are statistically 

significant at the 95-percent confidence level. 

75 Standard power wheelchairs accounted for 73 percent of Medicare’s power wheelchair 

expenditures in the first half of 2007 and 92 percent of the population we reviewed, which 

did not include power wheelchairs reimbursed under HCPCS codes K0813–K0817, 

K0820–K0822, and K0824–K0831. 
 

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FINDINGS

Figure 1 illustrates the differences between the percentage of error 

rates for claims for standard and complex rehabilitation power 

wheelchairs. 

 

Figure 1:

Percentage of Error Rates 

for Claims for Standard and

Complex Rehabilitation Power 

Wheelchairs, First Half of 2007 

Total errors: 61% Total errors: 56% 

Notes: In addition to claims for power wheelchairs that were medically unnecessary and claims that had insufficient

documentation, less than 1 percent of claims for standard power wheelchairs were undocumented. No claims for complex

rehabilitation power wheelchairs were undocumented. Error rates for claims for complex rehabilitation power wheelchairs

do not sum to 57 percent because of rounding.

Source: OIG medical record review of Medicare claims for power wheelchairs, 2010.

Standard power wheelchairs

Beneficiaries who received medically unnecessary standard power

wheelchairs needed either a different and less expensive type of

equipment or a more expensive power wheelchair, such as a complex

rehabilitation power wheelchair. For 2 percent of claims for standard

power wheelchairs, a less expensive manual wheelchair, cane, or walker

should have been provided. For another 3 percent of claims,

beneficiaries should have received power wheelchairs that were more 

expensive than the ones provided.

. In the first half of 2007, 61 percent of

Medicare standard power wheelchairs were medically unnecessary or

had claims that were insufficiently documented. Eight percent were

medically unnecessary, and another 53 percent had claims with 

insufficient documentation to determine medical necessity. In total, 

these errors for claims for standard power wheelchairs resulted in 

$90 million in inappropriate payments. 

76

76 For another 3 percent of claims, beneficiaries should have received a different power

wheelchair, but the reviewer could not determine which specific power wheelchair

beneficiaries needed. 
 

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FINDINGS

The difference in error rates between standard power wheelchairs 

supplied by low- and high-volume suppliers was not statistically 

significant. Sixty-six percent of standard power wheelchairs provided 

by low-volume suppliers were medically unnecessary or had claims that 

were insufficiently documented, and 60 percent of those provided by 

high-volume suppliers were medically unnecessary or had claims that 

were insufficiently documented.

Complex rehabilitation power wheelchairs

Beneficiaries who received medically unnecessary complex 

rehabilitation power wheelchairs needed a different and less expensive 

type of equipment, a less expensive power wheelchair, or a more 

expensive power wheelchair. For 1 percent of complex rehabilitation 

power wheelchair claims, a less expensive manual wheelchair should 

have been provided. For 13 percent of claims, beneficiaries should have 

received a less expensive power wheelchair than was provided, and for 

another 6 percent of claims, beneficiaries needed a more expensive 

power wheelchair.

. In the first half of 2007, 

56 percent of Medicare complex rehabilitation power wheelchairs were 

medically unnecessary or had claims that were insufficiently 

documented. Twenty-four percent of complex rehabilitation power 

wheelchairs were medically unnecessary, and another 32 percent had 

claims with insufficient documentation to determine medical necessity. 

In total, these errors for claims for complex rehabilitation power 

wheelchairs resulted in $5 million in inappropriate payments. 

77

Complex rehabilitation power wheelchair options and accessories. 

Nineteen percent of power options and accessories supplied with 

complex rehabilitation power wheelchairs were medically unnecessary 

or insufficiently documented. Four percent of the power options and 

accessories were medically unnecessary, and for another 16 percent of 

claims, beneficiaries’ medical records had insufficient documentation to 

determine whether the power options or accessories were medically 

necessary.78

77 For another 5 percent of claims, beneficiaries should have received a different power 

wheelchair, but the reviewer could not determine which specific power wheelchair 

beneficiaries needed. The types of claims for medically unnecessary complex rehabilitation 

power wheelchairs do not sum to 24 percent because of rounding.

 Fourteen percent of complex rehabilitation power 

wheelchairs were supplied with at least one medically unnecessary 

78 The medical necessity and insufficient documentation error rates do not sum to 

19 percent because of rounding.
 

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FINDINGS

power option or accessory.79 Medically unnecessary power options and 

accessories resulted in $2 million in inappropriate payments in the first 

half of 2007, separate from the inappropriate payments for power 

wheelchairs. 

Thirty-nine percent of power Prescribing physicians’ records do not 

wheelchair claims had no errors support the medical necessity of most based on suppliers’ records. power wheelchairs However, 78 percent of such 

claims were not supported by 

medical records kept by physicians who prescribed the power 

wheelchairs. Physicians’ records contradicted suppliers’ records for 

7 percent of claims with no errors based on suppliers’ records. These 

power wheelchairs were medically unnecessary based on physicians’ 

records. For another 71 percent of claims with no errors based on 

suppliers’ records, physicians’ records were insufficiently documented to 

determine medical necessity or the claims were undocumented. Table 2 

presents the types of errors in physicians’ records for claims with no 

errors based on suppliers’ records.

79 This analysis is based only on the 108 complex rehabilitation power wheelchairs 

supplied with at least 1 power option or accessory out of the 124 in the sample.
 

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FINDINGS

Table 2: Claims With Errors Based on Prescribing Physicians’ 

Records and No Errors Based on Suppliers’ Records, First Half of 

2007

Type of Error in Physician’s Record

Claims Error 

Rate

Power Wheelchair Was Medically Unnecessary 7%

Claim Had Insufficient Documentation To Determine Medical 

Necessity 62%

Claim Was Undocumented 9%

Total Claims 78%

Source: OIG medical record review of Medicare power wheelchair claims, 2010.

Physicians’ records sometimes contradicted suppliers’ records 

Seven percent of power wheelchair claims that were medically 

necessary based on suppliers’ records were medically unnecessary based 

on prescribing physicians’ records. In these cases, prescribing 

physicians’ records indicated that beneficiaries needed different power 

wheelchairs or did not need power wheelchairs at all. Examples of each 

of these types of claims from our sample are: 

• Claim F: The beneficiary’s weight is recorded as 230 pounds in the 

supplier’s record and as more than 350 pounds in the physician’s

record. The physician’s record also documents lower extremity edema 

and wounds. The supplier’s record does not note these impairments. 

The beneficiary received a standard power wheelchair, but based on 

the physician’s record, the patient needed a complex rehabilitation 

power wheelchair. A complex rehabilitation power wheelchair would 

have had a greater weight capacity and would have allowed for the 

addition of power options, such as elevating legrests and a power tilt 

seating system, to manage the lower extremity edema and allow 

wound healing and pressure relief.

• Claim G: In the supplier’s record, a letter from the physician states 

that the beneficiary was recovering from a total replacement of the left 

knee. The letter also states that the beneficiary has severe 

osteoarthritis, a history of brain surgery, and poor balance. Finally, 

the letter states that the beneficiary is obese, unable to walk safely 

with a cane or walker, and unable to propel a manual wheelchair 

because of severe joint pain. There is no documentation of a power 

wheelchair in the physician’s record. An entry from the physician’s 
 

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FINDINGS

record from 1 week after the date of the letter in the supplier’s record 

states that the beneficiary had recovered from the knee replacement 

enough to bear her full weight and discontinue using a cane. The 

beneficiary received a standard power wheelchair, but based on the 

physician’s record, she needed a cane or walker.

Physicians’ records often insufficiently documented the beneficiaries’ need 

for power wheelchairs 

Sixty-two percent of power wheelchair claims that were medically 

necessary based on the suppliers’ records were insufficiently 

documented in the physicians’ records. That is, the medical records 

from the prescribing physicians were insufficient to support the medical 

necessity of these power wheelchairs. For another 9 percent of claims 

that were medically necessary based on the suppliers’ records, 

physicians did not provide supporting medical records (i.e., the claims 

were undocumented). 

A physician is required to assess a beneficiary’s mobility needs before 

prescribing a power wheelchair. The report from the physician’s 

face-to-face examination, along with other documentation in the 

physician’s record, must support the medical necessity for the power 

wheelchair. Examples of claims that were insufficiently documented in 

the physicians’ records are: 

• Claim H: There is no documentation in the physician’s record from 

the entire year in which the beneficiary received a power wheelchair. 

However, physician documentation in the supplier’s record documents 

a mobility limitation and a risk of falls. It also documents 

significantly decreased strength in bilateral upper and lower 

extremities. 

• Claim I: Portions of the physician’s record were inconsistent 

regarding the beneficiary’s history of seizures. Therefore, it is unclear 

from the physician’s record whether the beneficiary had the mental 

and physical capabilities to safely operate the power wheelchair that 

was provided, a Medicare coverage requirement. In the supplier’s 

record, a note from a physical therapist documented that the 

beneficiary had not had a seizure in a long time.
 

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RECOMMENDATIONS 

A power wheelchair can greatly improve the quality of life for an 

individual with limited mobility. However, our review found that power 

wheelchairs paid for by Medicare are not always medically necessary, 

and claims for power wheelchairs frequently have insufficient 

documentation to support medical necessity. In the first half of 2007, 

Medicare paid $95 million for power wheelchair claims with these 

errors. Although CMS has taken steps since 2007 to decrease errors 

among suppliers of power wheelchairs and other kinds of DME, 

Medicare has paid significantly more in recent years for power 

wheelchairs than it did in 2007. Medicare and its beneficiaries paid 

$658 million in 2007, compared to $779 million in 2008 and $723 million 

in 2009. These increases may indicate that CMS continues to pay for 

power wheelchairs that are not medically necessary and/or have claims 

that do not meet documentation requirements. 

Additionally, we found that power wheelchairs that were medically 

necessary according to suppliers’ records were often not medically 

necessary according to the records of physicians who prescribed the 

power wheelchairs, a further indication of potential fraud, waste, and 

abuse. In most cases, physicians’ records had insufficient 

documentation to support the medical necessity of power wheelchairs 

and, less often, physicians’ records contradicted suppliers’ records. 

 

Two previous OIG reports based on the same sample of power 

wheelchairs found problems with suppliers’ compliance with Medicare 

requirements, and this report also shows such problems. Across all 

three reports, 80 percent of claims for power wheelchairs supplied to 

beneficiaries in the first half of 2007 did not meet Medicare 

requirements. In addition to finding in this report that 61 percent of 

claims were for power wheelchairs that were medically unnecessary or 

had insufficient documentation to determine medical necessity, OIG 

found in previous reports that 8 percent of claims were miscoded and 

60 percent did not meet documentation requirements. Many claims had 

more than one of these error types. 

Further, in recent years OIG has issued multiple reports identifying 

substantial vulnerabilities in the Medicare DMEPOS benefit, including 

deficiencies in enrollment safeguards, excessive payments, 

inappropriate payments, and issues with provider appeals. OIG has 

made a variety of recommendations to CMS to address these 

vulnerabilities. Finally, numerous DMEPOS suppliers have been 

convicted of Medicare fraud. 
 

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RECOMMENDATIONS

Based on the findings of this report and prior work, we recommend that 

CMS:

Enhance reenrollment screening standards for current DMEPOS suppliers 

Federal regulations categorize provider types into three levels of risk of 

fraud, waste, and abuse: limited, moderate, and high. New DMEPOS 

suppliers are placed at a risk level of “high,” whereas currently enrolled 

DMEPOS suppliers are placed at a risk level of “moderate.” Based on 

the overall error rate of 80 percent among power wheelchair claims, we 

believe that currently enrolled DMEPOS suppliers should be subject to 

the same enrollment screening standards as newly enrolling DMEPOS 

suppliers and should also be placed at the risk level of “high.”

Review records from sources in addition to the supplier, such as the 

prescribing physician, to determine whether power wheelchairs are 

medically necessary

In some cases in which the physicians’ records did not support the 

suppliers’ claims, the physicians’ records may not include the same level 

of detail in the suppliers’ records. Alternatively, the differences may 

exist because the suppliers’ records contained inaccurate information 

that was included to justify the medical necessity of a power wheelchair. 

Medicare contractors are not required to review the prescribing 

physician’s records, although in 2007 the CERT contractor began asking 

physicians for supporting information in response to OIG’s 

recommendation. We continue to recommend that CMS direct its 

contractors to review records from prescribing physicians as well as 

those of suppliers. 

Continue to educate power wheelchair suppliers and prescribing physicians 

to ensure compliance with clinical coverage criteria 

In 2009, CMS began requiring that DME suppliers meet quality 

standards to be accredited. Additionally, since the first half of 2007, 

CMS contractors have developed a variety of educational materials for 

power wheelchair suppliers and prescribing physicians. Our review 

highlights the importance of these efforts and the need for CMS to 

continue to educate, and promote collaboration between, suppliers and 

physicians. We suggest that CMS focus its educational efforts for 

suppliers and prescribing physicians on the following topics:

• Requirements for determining and documenting the medical necessity 

of a power wheelchair. We found that 9 percent of power wheelchairs 

were medically unnecessary and an additional 52 percent had claims 

with insufficient documentation for reviewers to determine medical 
 

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RECOMMENDATIONS

necessity. Suppliers’ records must show that the power wheelchairs 

they provided were medically necessary and met beneficiaries’ 

mobility needs. We suggest that CMS focus on suppliers of standard 

power wheelchairs because we found that claims for such 

wheelchairs were more likely to have insufficient documentation 

than those for complex rehabilitation power wheelchairs.

• Collaboration between supplier and physician necessary to determine 

the most appropriate power wheelchair for a beneficiary. Collaboration 

ensures that beneficiaries receive medically necessary power 

wheelchairs that are appropriate for their mobility needs. 

Additionally, we found that the 78 percent of claims for power 

wheelchairs that were medically necessary according to suppliers’ 

records were not supported by the records of the physicians who 

prescribed them. Collaboration between the physician and the 

supplier should also result in a consistent clinical assessment of the 

beneficiary and consistent supporting records.

• Requirements for determining the most appropriate power wheelchair 

for a beneficiary. We found that 7 percent of beneficiaries who 

received power wheelchairs needed a different type than was 

provided. Medicare covers hundreds of power wheelchair models 

that are reimbursed under 42 different HCPCS codes. These power 

wheelchairs vary widely in their ability to fulfill a beneficiary’s 

mobility needs. The wrong power wheelchair not only may fail to 

address a beneficiary’s mobility deficits but, in some cases, may 

harm the beneficiary. We suggest that CMS focus on suppliers of 

complex rehabilitation power wheelchairs because we found that 

such wheelchairs were more likely to be medically unnecessary than 

standard power wheelchairs and that the beneficiaries often needed 

a different type of power wheelchair.

Review suppliers of sampled claims we found to be in error

In a separate transmittal, we forwarded to CMS information—including 

the suppliers’ identifying information—about the 61 percent of claims 

that were for medically unnecessary power wheelchairs, were 

insufficiently documented to determine medical necessity, or were 

undocumented. We also provided CMS with information on the claims 

for which physicians’ records contradicted suppliers’ records, so that 

CMS may follow up appropriately. Finally, we will inform CMS of 

physicians for whom we could not obtain current addresses. (We have 
 

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RECOMMENDATIONS

informed CMS of suppliers for whom we could not obtain current 

addresses.)

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with the second, third, and fourth recommendations. 

CMS did not concur with the first recommendation. In response to the 

first recommendation, CMS stated that it has in place other tools that

allow for increased scrutiny of some current DMEPOS suppliers. CMS 

also noted that several triggering events can elevate individual 

suppliers from the “moderate” to the “high” risk level. Based on this 

report’s findings, which reinforce the findings of multiple OIG reports in 

recent years identifying substantial vulnerabilities in the Medicare 

DMEPOS benefit, we maintain that all current DMEPOS suppliers 

should be subject to the screening standards of the “high” risk level 

upon reenrollment. 

In response to the second recommendation, CMS stated that it will 

continue to emphasize the need for proper documentation from the 

prescribing physician. We support this initiative and believe that CMS 

contractors should consider collecting records directly from the 

physician in addition to the records that they collect from the supplier. 

In response to the third recommendation, CMS stated that it is 

committed to continuing education of providers and suppliers about 

Medicare clinical coverage criteria for power wheelchairs. Not only 

have CMS’s contractors provided education, but also CMS conducted an 

educational outreach call and published educational materials in 2010. 

In response to the fourth recommendation, CMS stated that it will share 

OIG-provided information with Recovery Auditors and MACs for 

appropriate followup. For the full text of CMS’s comments, see 

Appendix E. 
 

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 APPENDIX RECOMMENDATIONS ~ A

Clinical Coverage Criteria for Selected Power Wheelchairs

This appendix is adapted from the National Coverage Determination 

(NCD) for Mobility-Assistive Equipment and the Local Coverage 

Determination (LCD) for Power Mobility Devices. Information from the 

NCD has been incorporated in the LCDs, and we have included only the 

sections that are relevant to our evaluation. Full copies of these policies 

from all durable medical equipment regions can be found by searching 

the CMS Web site at 

http://www.cms.gov/mcd/search.asp?clickon=search. 

Basic Coverage Criteria

All of the following basic criteria (A–C) must be met for a power 

mobility device (Healthcare Common Procedure Coding System 

(HCPCS) codes K0800–K0898) to be covered.80 Additional coverage 

criteria for specific devices are listed below.

A) The patient has a mobility limitation that significantly impairs 

his/her ability to participate in one or more mobility-related activities of 

daily living (MRADLs), such as using the toilet, feeding, dressing, 

grooming, and bathing in customary locations in the home. A mobility 

limitation is one that:

• prevents the patient from accomplishing a MRADL entirely; or 

• places the patient at reasonably determined heightened risk of 

morbidity or mortality secondary to the attempts to perform a 

MRADL; or 

• prevents the patient from completing a MRADL within a reasonable 

timeframe.

B) The patient’s mobility limitation cannot be sufficiently and safely 

resolved by the use of an appropriately fitted cane or walker.

C) The patient does not have sufficient upper extremity function to 

self-propel an optimally configured manual wheelchair in the home to 

perform MRADLs during a typical day.

• Limitations of strength, endurance, range of motion, or coordination; 

presence of pain or deformity; and absence of one or both upper 

extremities are relevant to the assessment of upper extremity 

function.

80 CMS does not cover HCPCS codes K0865–K0898.
 

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APPENDIX A

• An optimally configured manual wheelchair is one with an 

appropriate wheelbase, device weight, seating options, and other 

appropriate nonpowered accessories.

Power Wheelchairs (HCPCS codes K0813–K0898)

A power wheelchair is covered if:

a. All of the basic coverage criteria (A–C) are met; 

b. The patient does not meet coverage criteria for a power-operated 

vehicle; 

c. Either criterion J or K[81

d. Criteria L, M, N, and O (see below) are met; and

] (see below) is met; 

e. Any coverage criteria pertaining to the specific wheelchair type (see 

below) are met.

J) The patient has the mental and physical capabilities to safely 

operate the power wheelchair that is provided; or

K) If the patient is unable to safely operate the power wheelchair, the 

patient has a caregiver who is unable to adequately propel an optimally 

configured manual wheelchair, but is available, willing, and able to 

safely operate the power wheelchair that is provided; and

L) The patient’s weight is less than or equal to the weight capacity of 

the power wheelchair that is provided.

M) The patient’s home provides adequate access between rooms, 

maneuvering space, and surfaces for the operation of the power 

wheelchair that is provided.

N) Use of a power wheelchair will significantly improve the patient’s 

ability to participate in MRADLs, and the patient will use it in the 

home. For patients with severe cognitive and/or physical impairments, 

participation in MRADLs may require the assistance of a caregiver.

O) The patient has not expressed an unwillingness to use a power 

wheelchair in the home.

81 Criteria D–I apply to a different type of power mobility device.
 

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APPENDIX A

Standard Power Wheelchairs 

Medicare covers standard power wheelchairs (HCPCS code K0823) if all 

of the power wheelchair coverage criteria are met and the beneficiary 

weighs less than 301 pounds.

Complex Rehabilitation Power Wheelchairs

Group 2 single power option (HCPCS codes K0835–K0840).[82] Medicare 

covers such wheelchairs if all of the power wheelchair coverage criteria 

are met and if criterion 1 or 2 is met and criterion 3 is met. 

1. The beneficiary requires a drive control interface other than a handor chin-operated standard proportional joystick (examples include 

but are not limited to head control, sip and puff, switch control). 

2. The beneficiary meets coverage criteria for a power tilt or a power 

recline seating system (see Appendix B), and the system is being 

used on the wheelchair.

3. The beneficiary has had a specialty evaluation performed by a 

licensed/certified medical professional, such as a physical therapist 

(PT) or occupational therapist (OT), or physician who has specific 

training and experience in rehabilitation wheelchair evaluations, 

and this specialty evaluation documents the medical necessity for 

the wheelchair and its special features. The PT, OT, or physician 

may have no financial relationship with the supplier.

Group 2 multiple power option (HCPCS codes K0841–K0843). Medicare 

covers such wheelchairs if all of the power wheelchair coverage criteria 

are met and if criterion 1 or 2 is met and criterion 3 is met.

1. The beneficiary meets coverage criteria for a power tilt and recline 

seating system (see Appendix B), and the system is being used on the 

wheelchair.

2. The beneficiary uses a ventilator mounted on the wheelchair.

3. The beneficiary has had a specialty evaluation performed by a 

licensed/certified medical professional, such as a PT or OT, or a 

physician who has specific training and experience in rehabilitation 

wheelchair evaluations, and this specialty evaluation documents the 

medical necessity for the wheelchair and its special features. The

82 Group 1 power wheelchairs (HCPCS codes K0813–K0816) are not included in this 

review.
 

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APPENDIX A

PT, OT, or physician may have no financial relationship with the 

supplier.

Group 3 with no power options (HCPCS codes K0848–K0855). Medicare 

covers such wheelchairs if all of the power wheelchair coverage criteria 

are met; the beneficiary’s mobility limitation is due to a neurological 

condition, myopathy, or congenital skeletal deformity; and the 

beneficiary has had a specialty evaluation performed by a 

licensed/certified medical professional, such as a PT or OT, or a 

physician who has specific training and experience in rehabilitation 

wheelchair evaluations, and this specialty evaluation documents the 

medical necessity for the wheelchair and its special features. The PT, 

OT, or physician may have no financial relationship with the supplier.

Group 3 with single power option (HCPCS codes K0856–K0860) or with 

multiple power options (HCPCS codes K0861–K0864). Medicare covers 

such wheelchairs if all of the power wheelchair coverage criteria are 

met; the beneficiary’s mobility limitation is due to a neurological 

condition, myopathy, or congenital skeletal deformity; and the Group 2 

single power option or multiple power options are met. 
 

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 APPENDIX ~ B

Clinical Coverage Criteria for Selected Power Wheelchair Power 

Options and Accessories 

This appendix is adapted from the Local Coverage Determination (LCD) 

for Wheelchair Options/Accessories. Full copies of this policy from all 

durable medical equipment regions can be found by searching the CMS 

Web site at http://www.cms.gov/mcd/search.asp?clickon=search

Arm of Chair

. 

Adjustable arm height option (E0973, K0017, K0018, K0020) is covered 

if the beneficiary requires an arm height that is different from that 

available using nonadjustable arms and the beneficiary spends at least 

2 hours per day in the wheelchair.

An arm trough (E2209) is covered if the beneficiary has quadriplegia, 

hemiplegia, or uncontrolled arm movements.

Footrest/Legrest

Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

1. the beneficiary has a musculoskeletal condition or a cast or brace 

that prevents 90-degree flexion at the knee; or

2. the beneficiary has significant edema of the lower extremities that 

requires having an elevating legrest; or

3. the beneficiary meets the criteria for and has a reclining back on the 

wheelchair. 

Nonstandard Seat Frame Dimensions

A nonstandard seat width and/or depth for a manual wheelchair 

(E2201–E2204) is covered only if the beneficiary’s dimensions justify the 

need.

Batteries/Chargers

Up to two batteries (E2361, E2363, E2365, E2371, K0731, K0733) at 

any one time are allowed if required for a power wheelchair.

A nonsealed battery (E2360, E2362, E2364, E2372) will be denied as not 

medically necessary.

A dual-mode battery charger (E2367) is not medically necessary; when 

it is provided as a replacement, payment is based on the allowance for 

the least costly medically appropriate alternative, E2366.
 

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APPENDIX B

Power Tilt and/or Recline Seating Systems (E1002–E1010):

A power seating system—tilt only, recline only, or combination tilt and 

recline—with or without power elevating legrests will be covered if 

criteria 1 and 2 are met and if criterion 3, 4, or 5 is met:

1. the beneficiary meets all the coverage criteria for a power wheelchair 

described in the LCD for Power Mobility Devices; and

2. a specialty evaluation performed by a licensed/certified medical 

professional, such as a PT or OT or physician who has specific 

training and experience in rehabilitation wheelchair evaluations of 

the beneficiary’s seating and positioning needs. The PT, OT, or 

physician may have no financial relationship with the supplier; and

3. the beneficiary is at high risk for development of a pressure ulcer 

and is unable to perform a functional weight shift; or

4. the beneficiary utilizes intermittent catheterization for bladder 

management and is unable to independently transfer from the 

wheelchair to bed; or

5. the power seating system is needed to manage increased tone or 

spasticity. 

Power Wheelchair Drive Control Systems

An attendant control is covered in place of a beneficiary-operated drive 

control system if the beneficiary meets coverage criteria for a 

wheelchair, is unable to operate a manual or power wheelchair, and has 

a caregiver who is unable to operate a manual wheelchair but is able to 

operate a power wheelchair.

Other Power Wheelchair Accessories

An electronic interface (E2351) to allow a speech-generating device to be 

operated by the power wheelchair control interface is covered if the 

beneficiary has a covered speech-generating device. 

Miscellaneous Accessories

An antirollback device (E0974) is covered if the beneficiary propels 

himself/herself and needs the device because of ramps.

A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak 

upper body muscles, upper body instability, or muscle spasticity that

requires use of this item for proper positioning.

One example (not all-inclusive) of a covered indication for swingaway, 

retractable, or removable hardware (E1028) would be to move the 
 

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APPENDIX B

component out of the way so that the beneficiary could perform a slide 

transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the 

beneficiary has one or more of the following conditions:

1. The beneficiary is at high risk for development of a pressure ulcer 

and is unable to perform a functional weight shift; or

2. The beneficiary utilizes intermittent catheterization for bladder 

management and is unable to independently transfer from the 

wheelchair to the bed.
 

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 APPENDIX ~ C

Table C-1: Population and Sample Sizes by Stratum, First Half of 2007

 Stratum Definition

Population Sample

Claims Expenditures Suppliers Claims Expenditures Suppliers

1 

Standard power wheelchair 

claims* by low-volume suppliers 7,223 $28,949,132 2,352 125 $499,152 124

2 

Standard power wheelchair 

claims* by high-volume suppliers 35,910 $144,354,060 716 125 $502,989 94

1 and 2

All standard power wheelchair 

claims* 43,133 $173,303,192 3,068 250 $1,002,141 218

3 

Complex rehabilitation power 

wheelchair claims** 3,001 $16,010,906 1,064 125 $665,200 113

 Total 46,134 $189,314,098 3,362+ 375 $1,667,341 325+

* Healthcare Common Procedure Coding System (HCPCS) code K0823.

** HCPCS codes K0835–K0864. + Suppliers’ figures do not sum to totals because of overlap (some suppliers in our sample provided standard and complex rehabilitation power wheelchairs). 

Source: Office of Inspector General analysis of Medicare power wheelchair claims with dates of service from January 1 to June 30, 2007.
 

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 APPENDIX ~ D

Table D-1: Estimates and Confidence Intervals for Power Wheelchair Error Rates, First Half of 2007

Estimate Description

Sample 

Size Point Estimate

95-Percent 

Confidence Interval

All Power Wheelchairs

Wheelchair was medically unnecessary 364 8.9% 5.7%–13.5%

Beneficiary needed a manual wheelchair, cane, or walker 364 1.6% 0.5%–5.0%

Beneficiary needed a different power wheelchair 364 7.3% 4.5%–11.5%

Beneficiary needed a less expensive power wheelchair 364 0.9% 0.6%–1.4%

Beneficiary needed a more expensive power wheelchair 364 3.0% 1.4%–6.3%

Reviewer could not determine specific power wheelchair that 

beneficiary needed 364 3.4% 1.6%–7.2%

Claim was insufficiently documented 364 51.7% 44.5%–58.7%

Claim was undocumented 364 0.1% 0.02%–0.9%

No errors 364 39.3% 32.6%–46.5%

 Total errors 364 60.7% 53.5%–67.4%

Standard Power Wheelchairs: All Suppliers

Wheelchair was medically unnecessary 240 7.8% 4.6%–12.9%

Beneficiary needed a manual wheelchair, cane, or walker 240 1.7% 0.5%–5.3%

Beneficiary needed a more expensive power wheelchair 240 2.8% 1.16%–6.5%

Reviewer could not determine specific power wheelchair that 

beneficiary needed 240 3.3% 1.5%–7.5%

Claim was insufficiently documented 240 53.1% 45.4%–60.6%

Claim was undocumented 240 0.1% 0.02%–1.0%

No errors 240 39.0% 31.9%–46.7%

 Total errors 240 61.0% 53.3%–68.2%

Standard Power Wheelchairs: Low-Volume Suppliers

 Total errors 120 65.8% 56.9%–73.8%

Standard Power Wheelchairs: High-Volume Suppliers

 Total errors 120 60.0% 51.0%–68.4%

Complex Rehabilitation Power Wheelchairs

Wheelchair was medically unnecessary 124 24.2% 17.5%–32.4%

Beneficiary needed a manual wheelchair 124 0.8% 0.1%–5.4%

Beneficiary needed a less expensive power wheelchair 124 12.9% 8.1%–19.9%

Beneficiary needed a more expensive power wheelchair 124 5.7% 2.7%–11.3%

Reviewer could not determine specific power wheelchair that 

beneficiary needed 124 4.8% 2.1%–10.3%

Claim was insufficiently documented 124 32.3% 24.7%–40.8%

Claim was undocumented 124 0% 0%–2.9%

No errors 124 43.6% 35.2%–52.3%

 Total errors 124 56.5%* 47.7%–64.8%

* Point estimate is rounded from 56.45% to 56.5%. 

Source: Office of Inspector General (OIG) medical record review of Medicare power wheelchair claims, 2010.
 

OEI - 0 4 - 0 9 - 00260 MOST MEDICARE P OWER W HEELCHAIRS D ID N OT MEET MEDICAL NECESSITY GUIDELINES 41

APPENDIX D

Table D-2: Estimates and Confidence Intervals for Comparisons of Error Rates by Power 

Wheelchair Type, First Half of 2007

Estimate Description

Sample 

Size 

Point 

Estimate 

95-Percent 

Confidence Interval P-Value

Comparisons of Standard Versus Complex Rehabilitation Power Wheelchairs

Difference in percentage of power 

wheelchairs that were medically unnecessary 364 16.4%* 8.0%–24.9% 0.0002

Difference in percentage of power 

wheelchairs with claims that were 

insufficiently documented or were 

undocumented 364 20.9%** 9.8%–32.1% 0.0003

* Twenty-four percent of complex rehabilitation power wheelchairs were medically unnecessary and 8 percent of standard power wheelchairs 

were medically unnecessary.

** Fifty-three percent of claims for standard power wheelchairs were insufficiently documented and 32 percent of claims for complex 

rehabilitation power wheelchairs were insufficiently documented.

Source: OIG medical record review of Medicare power wheelchair claims, 2010. 

Table D-3: Estimates and Confidence Intervals for Inappropriate Payments for Power 

Wheelchairs With Errors, First Half of 2007

Estimate Description

Sample 

Size Point Estimate*

95-Percent Confidence 

Interval*

All Power Wheelchairs

Insufficient documentation 364 $93,227,220 $80,467,932–$105,986,508

 Total errors 364 $95,182,002 $82,376,901–$107,987,103

Standard Power Wheelchairs: All Suppliers

 Total errors 240 $89,983,213 $77,245,694–$102,720,732

Complex Rehabilitation Power Wheelchairs

 Total errors 124 $5,198,789 $3,884,930–$6,512,648

* Dollar figures are rounded to the nearest whole dollar.

Source: OIG medical record review of Medicare power wheelchair claims, 2010.
 

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APPENDIX D

Table D-4: Estimates and Confidence Intervals for Error Rates and Inappropriate Payments 

for Power Options and Accessories, First Half of 2007

Estimate Description

Sample 

Size 

Point 

Estimate 

95-Percent 

Confidence Interval

Power option or accessory was medically unnecessary 

or insufficiently documented 556 19.4% 14.5%–25.6%

Power option or accessory was medically unnecessary 556 3.8% 2.2%–6.3%

Power option or accessory was insufficiently 

documented 556 15.7% 11.2%–21.5%

One or more options or accessories provided with 

power wheelchair were medically unnecessary 108 13.9% 8.6%–21.6%

Power option or accessory error 556 $1,908,688 $856,598–$2,960,778

Note: Dollar figures are rounded to the nearest whole dollar.

Source: OIG medical record review of Medicare power wheelchair claims, 2010.

Table D-5: Estimates and Confidence Intervals for Types of Errors in Physicians’ Records 

for Claims With No Errors Based on Suppliers’ Records, First Half of 2007

Estimate Description

Sample 

Size 

Point 

Estimate 

95-Percent 

Confidence Interval

Claims for power wheelchairs that were medically 

necessary based on supplier record but medically 

unnecessary based on physician record 121 6.9% 2.4%–18.2%

Claims for power wheelchairs that were medically 

necessary based on supplier record but insufficiently 

documented based on physician record 121 62.1% 49.1%–73.6%

Claims for power wheelchairs that were medically 

necessary based on supplier record but undocumented 

based on physician record 121 8.7% 3.7%–19.1%

Claims for power wheelchairs that were medically 

necessary based on supplier record but medically 

unnecessary, insufficiently documented, or undocumented 

based on physician record 121 77.7% 65.7%–86.4%

Source: OIG medical record review of Medicare power wheelchair claims, 2010.
 

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APPENDIX D  APPENDIX ~ D

Table D-6: Estimates and Confidence Intervals for Combined Error Rate Across Three 

Reports, First Half of 2007

Estimate Description Sample Size

Point 

Estimate 

95-Percent Confidence 

Interval

Combined error rate—claims reviewed in all three 

reports 339 79.8% 72.9%–85.4%

Combined error rate—claims reviewed in at least 

one report 365 78.9% 72.2%–84.3%

Sources: OIG medical record review of Medicare power wheelchair claims, 2010; HHS OIG, Miscoded Claims for Power Wheelchairs in the 

Medicare Program, OEI-04-07-00403, July 2009; and HHS OIG, Medicare Power Wheelchair Claims Frequently Did Not Meet Documentation 

Requirements, OEI-04-07-00401, December 2009.
A P PEN D x E 


Agency Comments 

...."".or...'" 

(~.# DEPARl'MENT OF HEACfH & HUMAN SERVlCFS Centers lor Medicare & Medicaid Services 

DATE: 

TO: 

FROM: 

SUBJECT: 

Ad",inistrator 

Washington. DC 20201 

APR 2 7 2011 

Daniel R. Levinson 

Inspector General 

Donald M. Berwick. M.D. 

Administrator 

Office ofInspector General (OIG) Draft Report: "Most Power 

Wheelchairs in the Medicare Program Did Not Meet Medical Necessity 

Guidelines" (OEl-04-09.Q0260) 

Thank you for the opportunity to review and comment on the above OlG draft report. 

The Centers for Medicare & Medicaid Services (eMS) appreciates the time and resources 

DIG has invested in determining the extent to wbich Medicare improperly paid claims for 

powerwheelcbairs. eMS is keenly focused on tbe issues related to power wheelchairs in 

the Medicare program. We appreciate DIG's work in this area. Since 2009. OlG has 

issued two reports based on the same sample of claims used in this study that assessed 

compliance wi th different Medicare requirements for power wheelchairs. Across the 

three reports, the 010 found that 80 percent of power wheelchairs provided in the first 

half of2007 did not meet Medicare requirements. This particular study found that 61 

percent ofpower wheelchair claims were not medically necessary or lacked sufficient 

documentation to determine medical necessity. eMS understands that inadequate and/or 

insufficient documentation is a significant problem associated with power wheelchair 

claims. 

As mentioned in the report, eMS is actively engaged in improving provider and supplier 

compliance with Medicare's power wheelchair requirements. In January 2011, eMS 

updated the payment policy for power wheelchairs, eliminating the up-front purchase 

option and keeping the rent-to-own option. Previously, Medicare allowed for either an 

up-front purchase or a rental period that would lead to ownership after 13 months. The 13 

month period allows additional opportunities for eMS to potentially conduct review on 

power wheelchair claims. 

The CMS continues to support efforts to reduce improper power wheelchair payments, 

including increased prepayment reviews of power wheelchairs. Moreover, eMS plans to 

pursue additional provider and supplier education to ensure suppliers and prescribing 

physicians understand Medicare's coverage and documentation requirements for power 

wheelchairs. 

OEI·04·09·00260 MOST MEDICARE POWER WHEELCHAIRS DID NOT MEET MEDICAL NECESSITY GUIDELINES 44 
 

OEI - 0 4 - 0 9 - 00260 MOST MEDICARE P OWER W HEELCHAIRS D ID N OT MEET MEDICAL NECESSITY GUIDELINES 45

APPENDIX E
 

OEI - 0 4 - 0 9 - 00260 MOST MEDICARE P OWER W HEELCHAIRS D ID N OT MEET MEDICAL NECESSITY GUIDELINES 46

APPENDIX E
 

OEI - 0 4 - 0 9 - 00260 MOST MEDICARE P OWER W HEELCHAIRS D ID N OT MEET MEDICAL NECESSITY GUIDELINES 47

APPENDIX E
 

OEI - 0 4 - 0 9 - 00260 MOST MEDICARE P OWER W HEELCHAIRS D ID N OT MEET MEDICAL NECESSITY GUIDELINES 48

 ACKNOWLEDGMENTS

This report was prepared under the direction of Dwayne Grant, 

Regional Inspector General for Evaluation and Inspections in the 

Atlanta regional office, and Sarah Ambrose and Jaime Durley, Deputy 

Regional Inspectors General. 

Other principal Office of Evaluation and Inspections staff from the 

Atlanta regional office who contributed to the report include 

Holly Williams; central office staff who contributed include 

Berivan Demir Neubert, Kevin Farber, and Scott Manley. 
 

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 & 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 Office of Audit Services (OAS) provides 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. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS.

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties.

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 for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.