HCPCS Public Meeting Information

Yesterday, CMS published the agenda for its first biannual HCPCS Public Meeting, which will be held virtually from June 7-10th. The Public Meeting allows individuals and companies that have submitted requests for new codes to respond to the HCPCS Coding Workgroup’s decisions, which are included in the agenda just posted on CMS’s website.

Here are the most relevant decisions for prosthetic and orthotic devices:

1. L2006 Preliminary Benefit Category and Payment Determination. The Workgroup designated L2006 as part of the Leg Brace (Orthotic) benefit category and set a preliminary average fee schedule amount of $33,810 for that code. The predicate device for which L2006 was created is Ottobock’s C-Brace.
    
2. K1014 Preliminary Benefit Category and Payment Determination. The Workgroup designated K1014 as part of the Artificial Leg (Prosthetic) category and set a preliminary average fee of $6,463.27 for that code. The predicate device for which K1014 was created is Proteor’s ALLUX knee.
    
3. K1022 Preliminary Benefit Category and Payment Determination. The Workgroup designated K1022 as part of the Artificial Leg (Prosthetic) category and set a preliminary average fee of $676.08 for this code. The predicate device for which K1022 was created is Ottobock’s 4R57 Rotation Adapter.
    
4. K1007 Preliminary Benefit Category and Payment Determination. The predicate device for which K1022 was created is the ReWalk Exoskeleton System. The Workgroup declined both to classify K1022 as part of the Leg Brace benefit category and to provide a preliminary fee schedule determination. Until additional guidance is issued, the DME MACs will have discretion to cover and pay for items described by K1007 as they see fit.
    
5. L8701 Preliminary Benefit Category and Payment Determination. The predicate device for which L8701 was created was the Myomo MyoPro. The Workgroup declined both to classify L8701 as part of the Arm Brace (Orthotic) benefit category and to provide a preliminary fee schedule determination. Until additional guidance is issued, the DME MACs will have discretion to cover and pay for items described by L8701 as they see fit.

What Does This Mean for You?

A few observations of potential interest about what the publication of the first biannual HCPCS Public Meeting suggests:

• This is the first time the HCPCS Coding Workgroup has issued an agenda since being granted the explicit authority to set pricing for codes. (Historically, a separate Pricing Workgroup was responsible for this activity.) Interestingly, the Coding Workgroup did provide an explanation of how it determined the preliminary fees, a significant change from the historical “black box” approach that characterized this process since at least 2006.

With pricing now in the HCPCS Coding Workgroup’s domain, this will be the first time that discussions about the perceived adequacy/inadequacy of the fees themselves and the underlying methodology used to arrive at them will happen in public. We would expect direct feedback from applicants and other stakeholders regarding preliminary pricing decisions, especially for those products listed above for which the applicants believe the preliminary pricing is too low

We will keep you posted as new information about any of these codes becomes available.