Durable Medical Equipment, Prosthetics, Orthotics, and Supplies – Assigning the Correct Code

While the AMA CPT Manual does not address durable medical equipment, prosthetics, orthotics, and supplies (aka DMEPOS), the HCPCS Manual does. Unlike the AMA CPT Manual, the HCPCS Manual often lacks coding rules or guidelines to help determine coding. To complicate matters, few Medicare NCCI edits exist for DMEPOS. Medicare openly admits that they do not publish all edits, since some are proprietary. However, despite a lack of published guidelines in the HCPCS manual or in the Medicare NCCI Manual and tables, guidelines do exist that help establish correct coding for DMEPOS.

Depending on the device, individuals can find some guidance through local coverage determinations (aka LCDs) and their corresponding articles that help establish how to use the codes and when.

Some devices may even appear on the Pricing, Data Analysis, and Coding (aka PDAC) website, which assigns specific code(s) to a device. At times, more than one code may be assigned to a device with limitations on when a specific code should be used.

In addition to the PDAC website, LCDs, and LCD articles, the Food and Drug Association (aka FDA) premarketing notifications may tell us the category the device has been assigned. When this is combined with information from the manufacturer, coders now have a better idea of how to properly code services, especially where there is no LCD, LCD article, or PDAC information.

With regards to NCCI edits, we must turn to Medicaid NCCI edits to identify the coding combinations for the devices since these are often published whereas Medicare’s are proprietary. Since the passage of the Affordable Care Act or ACA, state Medicaid agencies must adopt NCCI edits. Thus, Medicare’s proprietary edits became public. States can request waivers or modify them to their state programs, but they can provide the basic information needed for correct coding utilized by many carriers.

Through these various sources, there may be information on coverage, including any lifespan of the devices. Many times, Medicare or other carriers will not replace the devices until after the lifespan of the device has been met. This may be 5 years for many of these devices.

It is this lifespan that provides many DME suppliers an opportunity to rent some devices to multiple patients and obtain more money than the purchase price for that device. This is why the modifiers for the DME codes are so important as they could impact pricing.

Finally, since DMEPOS includes supplies, both the Medicare Physician Fee Schedule and the CPT Manual address supplies. The good part is that this assists coders. Together we will take a closer look at these resources and learn how to code DMEPOS.

• Local Coverage Determinations (LCD)
• LCD Associated Articles
• NCCI Edits
• National Medicare contractor for Pricing, Data Analysis and Coding (PDAC)
• FDA Premarketing Notification
• Manufacturer Suggested Coding
• DME Modifiers
• Supplies in a Physician’s Office
• DME Coverage, including Shelf Life/Lifespan

A lack of clear and published rules in the HCPCS manual may lead to confusion about coding durable medical equipment, prosthetics, orthotics, and supplies correctly. Limited resources and/or productivity standards limit the ability to research how to correctly code these services or find the information needed to code these services timely and accurately. This can lead to inconsistency in billing and even inappropriate billing that could lead to denials or incorrect reimbursement.

Together we will explore the rules and guidelines that exist for DMEPOS so we can code correctly, timely, and consistently.

• Coders
• Practice Managers
• Compliance Officers
• Auditors
• Policy Specialists
• Revenue Cycle Management Teams
• Payment Integrity Investigators/Analysts.