Coding Issues

Coding Verification for Hip Abduction Orthosis

The DME MACs and the PDAC released a correct coding reminder for the hip abduction orthosis, L1686 (HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment).  L1686 contains a semi-rigid or rigid waistband connected to a single rigid upright, hip joint and rigid thigh cuff.  The hip joint is adjustable for extension/flexion as well as abduction; the hip joint aligns and maintains the femur in an abducted position. The L1686 is also considered to be a complete product/device. It is also considered to be custom fitted and requires more than minimal self-adjustment at the time of delivery and requires the expertise of a certified orthotist or an individual who has specialized training in the provision of an orthosis to fit the item to the beneficiary.

Coding Verification for Lower Limb Prostheses

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and Pricing, Data Analysis, and Coding Contractor (PDAC) released a joint announcement for a new coding verification requirement for the six lower limb prostheses. Effective for claims with dates of service on or after January 1, 2021, the only products which may be billed using codes L5856, L5857, L5858, L5973, L5980, and L5987 are those for which a written Coding Verification Review has been made by the PDAC and is listed on the PDAC Product Classification List.  The joint publication announcing the coding verification requirement may be viewed here.

Coding Reminder for Scoliosis Braces

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis and Coding (PDAC) contractor just released a correct coding reminder for five base codes used to describe scoliosis braces: L1000, L1005, L1200, L1300 and L1310.  A copy of the full correct coding reminder may be found here.

2020 HCPCS Code Changes & Fee Schedule Update

The Centers for Medicare and Medicaid Services (CMS) has released the new Healthcare Common Procedure Coding System (HCPCS) codes and fee schedule amounts for 2020, and there were a few minor changes. The changes which will be effective for claims with a date of service on or after January 1, 2020.

Medicare Correct Coding Guidelines

Each supplier is ultimately responsible for the HCPCS code(s) they select to bill for the items provided. Resources like code determinations letters and DMECS are useful but many products have not been reviewed. For these un-reviewed products, each supplier must use their best judgment in selecting HCPCS codes for billing. Here are some tips that will help:

  • Check the PDAC Product Classification Lists on DMECS. Although not every HCPCS code has an associated product list, many of the most commonly used codes do.
  • Check the DME MAC publications for coding bulletins and coding guidelines related to products and HCPCS codes for specific information on the item of interest.
  • Refer to the “long” code narrative. All codes have short and long descriptors. The long descriptor often provides more detail regarding the requirements for the code. Select the code with the descriptor that most closely describes the product.
  • Most code narratives are written broadly to be all-inclusive. You may not find a specific code that perfectly matches a product. Use the code that most closely describes the item rather than a NOC (not otherwise classified) or miscellaneous code.
  • Local Coverage Determination related Policy Articles often have additional information in the Coding Guidelines section. Coding guidelines provide additional information on the characteristics of products that meet a specific HCPCS code.
  • Remember that price and fees are NOT part of correct coding. Selecting a code based upon the fee schedule almost always results in an incorrect coding determination. HCPCS codes describe the product not the price.
  • Check with the PDAC. The PDAC Contact Center can provide information that will assist you in code selection. This assistance, however, is NOT considered a formal product review. The advice provided is not an official code determination.  Items are not added to the DMECS Product Classification List based on a query to the PDAC Contact Center.
  • Request that manufacturers submit their products for coding. Although some HCPCS codes require mandatory product review in order to use the code, for most codes product review is voluntary. Many manufacturers are responsive to their customer’ requests for verified HCPCS coding.

Items Requiring Coding Review by the PDAC

Manufacturers and patient care facilities are reminded that a number of items require coding review by the Pricing, Data Analysis and Coding (PDAC) contractor; and a PDAC coding review is binding when billing Medicare. Here is a list of items which require a PDAC coding review and the PDAC’s Product Classification List.