At SPS, we take pride in our goal of being an educational resource to our team members, customers, partners, and more. In this Xpress issue, we dug deep into the orthotic and prosthetic regulation foundation to provide guidance for current coding and policy, specifically PDAC, as it launched new regulations this past year.
Pricing, Data Analysis and Coding, or better known as PDAC, plays a pivotal role in the regionalization of medical equipment claim processing. The objective of PDAC (under the authorization or request by CMS, DME MACs, or a manufacturer) is to review products and determine the correct codes based on policy. PDAC itself doesn’t make the policies; it creates determinations based on Medicare policies. They have to follow Medicare guidelines, the same guidelines that you as a clinician follow during the billing process. Therefore, if there is a prosthetic foot that has not been reviewed by PDAC, an appropriate coding determination can be made based on Medicare policy.
In the summer of 2020, PDAC and DME MACS announced the “Requirement” for PDAC Verification of six Lower Limb prosthetic L-Codes for dates of service on or after January 1, 2021. These same six L-Codes also required Prior Authorization as a condition of payment starting September 1, 2020 in PA, TX, MI, and CA. the nationwide rollout started December 1, 2020. The Prior Authorization program does not have any new documentation requirements; it simply requires the information to be submitted earlier in the claims process.
How it Works
You can request Prior Authorization (PA) and send the documentation of medical necessity ahead of time. This submission should take place before the prosthesis is created, possibly before product components are bought (typically out of pocket). If you receive an affirmative PA confirmation, proceed with servicing the patient. If a product receives a Non-Affirmative PA, it can be due to a number of reasons such as, but not limited to the PA request may be missing some functional documentation or the doctor’s signature does not comply with Medicare Policy. It could also indicate that something in the medical records does not meet policy requirements. With a Non-Affirmed PA, the DME MAC will notify you of the items that need correction. Requests for Prior Authorization can be re-submitted an endless amount of times.
What Can Clinicians Do?
The most important thing a clinician can do is to educate themselves and their team on these policies. Reference the most recent Lower Limb Prosthetic LCD, related Policy Articles, Standard Documentation Article, and DME MAC articles and bulletins or correct coding guidelines and documentation requirements. All these policies can easily be found on the Medicare Coverage Database website. Also, make sure you are familiar with your DME MAC Jurisdiction website to find helpful Provider Outreach Education.
Below you will find key links to help tackle the policy and regulation process:
- Local Coverage Determination (LCD) and Lower Limb Prostheses (L33787)
- Lower Limb Prostheses—Policy Article (A52496)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- DME MAC—Noridian (JA and JD) Healthcare Solutions
- DME MAC—CGS (JB and JC) A Celerian Group Company
- Palmetto GBA website (which allows you to search the DME POS product classification list)
- AOPA's guide to Coding Issues
Navigating PDAC on SPS
Click the buttons below to browse PDAC-approved items or use the buttons located on the SPS Online Store homepage.
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Study-up at the SPS Learning Center Check-out the learning center for key PDAC resources. |
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In the 7th episode of The SPS Check-in, Regina Weger chats with Blatchford's VP of Sales & Marketing Ben Auzenne about current regulatory changes impacting the industry. |
View the original feature in SPS Xpress
