Medicare Pricing Data Analysis and Coding (PDAC) verification rules are often misunderstood, specifically when it pertains to coding and documentation. While many O&P suppliers have only heard of these rules, some have experienced claim denials due to lack of compliance. Unfortunately, Medicare policy falls short in educating the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) community about how to be compliant with this coding requirement. For suppliers to prevent claim denials, it is essential to review and apply compliance best practices to ensure all claim requirements for PDAC verification are satisfied.
Since not all Healthcare Common Procedure Coding System (HCPCS) codes require PDAC verification, the first step is identification. The PDAC website has a helpful resource on its website (dmepdac.com) that lists all O&P specific HCPCS codes that require PDAC verification, including codes for orthoses, prostheses, and diabetic inserts. If applicable, these codes are also identified in the respective Policy Article for each type of device.
Once suppliers have identified whether the HCPCS on their claims require PDAC verification, they can “audit-proof” the claims for this specific requirement. The intent of the PDAC verification requirement is to identify the exact product that was provided to the patient that is being billed under that HCPCS code. For example, Medicare not only wants to know that a supplier provided a double upright knee orthosis (L-1845), but also that a supplier provided an Advanced Orthopaedics ACL Knee Brace 85X-L. This level of specificity does not necessarily need to be included on the claim in any capacity, it just needs to be included in the supplier documentation. As best practice, O&P Insight recommends including the manufacturer name, product name, and model number either on the proof of delivery documentation or within the clinician notes. Overlooking just one of these elements could render a claim reviewer unable to determine the exact item that was provided to the patient, resulting in a claim denial.
O&P Insight recommends utilizing the Durable Medical Equipment Coding System (DMECS) on the PDAC website as a tool for ensuring compliance with the PDAC verification requirement. A supplier’s team can enter one or all the elements (e.g., HCPCS code, manufacturer, product name, and product model) into the search fields under the Product Classification List. If an exact match is not returned, the product is not sufficiently detailed and could render a claim denied. This tool can also be utilized in reverse, by finding a specific product on the DMECS search and using the descriptions listed in your documentation to ensure compliance with this stringent requirement.
There are numerous, sometimes uncontrollable, reasons claims can be denied. Fortunately, if suppliers use these tools and tips, they can prevent denials related to the PDAC verification requirements nearly 100 percent of the time.
Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are part of the leadership team at O&P Insight. Sisson and Bertram have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can contact them at [email protected] or [email protected]. Michelle Wullstein, CPCO, has been in the Medicare profession for over 18 years and is an AAPC-certified professional compliance officer and provides O&P specific medical policy, billing, documentation, and HIPAA compliance support to internal teams and clients.
While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.
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