Taking a Step in the Right Direction
by Joe McTernan, AOPA Government Affairs Department

Last year, AOPA, in conjunction with the O&P Alliance, met with representatives from the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) to discuss a potential overhaul of HCPCS codes that describe prosthetic feet. One of the goals of the SADMERC is to reduce the overall number of codes while creating a new code set that better represents the range of commercially available prosthetic feet.

Specifically, the SADMERC was looking for contact information for manufacturers of prosthetic feet so that it could solicit feedback regarding the proposed code set.

AOPA recognized the outstanding opportunity this project presented and suggested a slightly different approach. Rather than soliciting feedback from each manufacturer individually, AOPA suggested that the SADMERC allow AOPA to moderate a meeting of representatives from all of the interested prosthetic foot manufacturers. The purpose of this meeting would be to develop a clinically sound set of codes that accurately reflects modern prosthetic foot technology.

In addition to the code set, AOPA proposed the development of coding standards that could be used to test and verify specific characteristics of prosthetic feet. The SADMERC agreed to this proposal, and the AOPA prosthetic foot workgroup was created.

The workgroup, chaired by Thomas DiBello, CO, LO, FAAOP, a member of AOPA’s Coding and Reimbursement Committee, has now met on five occasions. It has made significant progress in developing a revised code set that will meet the needs of the SADMERC, while at the same time accommodating existing products available in the marketplace. The philosophy behind the proposed code set also encourages continued research and development of new and innovative products.

The workgroup has focused on the functional characteristics of prosthetic feet in creating code language that is easy to understand. At the same time, the code set is split into “base” addition codes that describe functional characteristics of both the keel and heel section of the foot, and “feature” addition codes that describe unique functional characteristics of the foot. Various combinations of these base and feature codes allow prosthetic practitioners to describe the function of the prosthetic foot that best meets the needs of their individual patient.

In addition to creating a proposed code set for prosthetic feet, the workgroup is also developing testing standards that will clearly define what thresholds must be met in order for a prosthetic foot to be described by a specific code. Currently, there is no way to objectively determine whether a particular prosthetic foot meets the functional requirements of a code. One goal of the workgroup is to create simple, repeatable tests that can be used to verify the functional characteristics of a prosthetic foot.

One of the highlights of the project so far is the high level of cooperation that exists among the manufacturer representatives present at the meetings. With more than ten different prosthetic foot manufacturers represented, each with their own individual interests, their ability to work toward a goal that will benefit the O&P community as a whole has been remarkable. Without this unprecedented level of professionalism and commitment to the successful outcome, the workgroup would not have accomplished as much as it has.

In March 2008, AOPA representatives met with the SADMERC to present a preliminary report on the progress of the workgroup. This meeting went very well and the SADMERC expressed its support for the workgroup to continue. The workgroup expects to present its complete proposal to the SADMERC in time for inclusion in the 2009 HCPCS update.

If time constraints do not allow this to occur, the SADMERC has the authority to establish temporary “K” codes at any time during the year. The workgroup is hopeful that the final proposed code set will be accepted and implemented during 2009.

While there is no guarantee that what is eventually provided to the SADMERC will be accepted in full, AOPA is encouraged by the reception our interim proposal received. In addition, if this effort is successful, it will provide us with a template for moving forward on other sections of the HCPCS L codes, since the SADMERC has indicated that it wishes to revise the whole code set over the next several years.

Joe McTernan is director of reimbursement services for AOPA. Questions? Call (571) 431-0876,
ext. 211, or e-mail jmcternan@AOPAnet.org.