Exciting New Development: Upper Extremity Correct Coding Guidance Has Been Retired

DME MACs and PDAC Announce Retirement of Correct Coding Guidance for Upper Extremity Prostheses

On March 15, 2023, the DME MACs and PDAC announced the retirement of their previously published correct coding guidance for upper extremity prostheses.  The correct coding guidance, originally published on March 31, 2022 resulted in significant concern from AOPA and its partners in the O&P Alliance about the impact the correct coding guidance was having on access to clinically appropriate, medically necessary upper extremity prosthetic care, not only for Medicare beneficiaries but also for individuals covered by other insurers who adopted the correct coding guidance into their own policy decisions.

The O&P Alliance submitted extensive written comments regarding its concern about the correct coding guidance shortly after it was published.  After several months of follow up communication, on March 9, 2023, AOPA and the O&P Alliance had a very productive meeting with CMS representatives, the DME MACs, and PDAC where we were able to reiterate our concern about the correct coding guidance and how, less than a year after its publication, it was significantly hindering access to care for Medicare beneficiaries and others.

The DME MAC and PDAC medical directors indicated that the intention of all correct coding guidance is to assist providers in understanding how to properly describe the services they are providing and explained that their guidance is never meant to create new or revised coverage policy.  The medical directors suggested that they would consider retiring the correct coding guidance if it was creating more confusion than clarification for providers and beneficiaries alike.

Less than a week after meeting with the AOPA and the O&P Alliance, the DME MACs and PDAC announced the official retirement of the previously published upper extremity prostheses correct coding guidance.  This extremely positive development shows the incredible value of open and trusted communication. There is still work to be done and collaboration will be the key but the retirement of the correct coding guidance is an important step in working toward the development of proper guidance that will ensure adequate access to clinically appropriate, medically necessary upper extremity prosthetic care for Medicare beneficiaries.

AOPA will work with its O&P Alliance partners to make sure that this great work continues.

Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.