BREAKING NEWS: DME MACs and PDAC Retire Coding Guidance for Upper Extremity Prosthetics

The Issue:

In March 2022, the DME MACs and PDAC published an article titled, “Upper Limb Prostheses – Correct Coding.” This guidance laid out a comprehensive description of upper extremity prosthetic codes and, importantly, limited the use of certain codes in conjunction with others. This disrupted the historical understanding and use of those codes by prosthetists, impairing beneficiaries’ access to certain types of upper extremity prostheses.

The March 2022 “Correct Coding” article built on and expanded guidance issued by the DME MACs and PDAC in late 2019. Össur was one of several stakeholders that worked together with AOPA beginning in 2020 to address that original guidance. The publication of the 2022 article resulted in the expansion of those efforts to the O&P Alliance, which submitted comprehensive comments to the MACs and PDAC last year.

What You Need to Know:

Following a meeting with members of the O&P Alliance two weeks ago, the DME MACs and PDAC announced the retirement of the March 2022 “Correct Coding” article. The title of that article has been changed to, “RETIRED – Upper Limb Prostheses – Correct Coding,” and the following disclaimer now precedes the article’s body:

IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.

Content provided on this page contains outdated information and instruction and should not be considered current. [The DME MAC] is providing this archived information for research purposes only. This archived article contains previously issued instructions that have since been updated or are no longer applicable for Medicare billing purposes. [emphasis added]

What This Means for You:

While we cannot predict exactly how the DME MACs will process upper extremity claims moving forward, the disclaimer quoted above states that its instructions no longer apply “for Medicare billing purposes.” Importantly, the MACs/PDAC have not issued an update to this article, so the “update” reference in the final sentence does not apply to this situation. That leaves the “no longer applicable for Medicare billing purposes” language as the functional guidance for O&P’s at this time.

To the extent that commercial health plans and Workers Compensation carriers have adopted the March 2022 guidance as part of their coverage criteria, we expect that the retirement of this article will not trickle down to those medical policies immediately. Some commercial plans may voluntarily follow the MACs’/PDAC’s lead at some point in the future but others likely will not. Since virtually all upper extremity prosthetic claims in the commercial health plan world require prior authorization, you should counter any authorization denials based on the “Correct Coding” guidance by referencing the retirement of that article when appealing.

We will keep you updated if and when any new information relevant to this issue becomes available.