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Linda Collins Blogger

Does a Product Have to be Listed on PDAC?

Posted by Linda Collins | November 05, 2015

The PDAC (Pricing, Data Analysis and Coding) is a Medicare contractor that fulfills several functions. In this post, we're going to focus on one of them: its role as a verifier of correct coding for prosthetic and orthotic devices.

Does the PDAC review all prosthetic and orthotic components?

No. Historically, the PDAC has not required manufacturers to submit any prosthetic components for coding verification. This means that any prosthetic devices listed on the PDAC's website either (a) were submitted voluntarily by the device's manufacturer, or (b) received a code from Medicare's HCPCS Coding Workgroup, a decision that PDAC is required to follow and that it publishes on its site.

On the orthotic side, PDAC has required mandatory submission of products, but only for certain L codes. In the instance where PDAC requires verification in order to bill a particular code, you cannot bill Medicare fora device using that code unless it has gone through the verification process. A list of the few HCPCS codes which do require PDAC verification is found here.

If a product doesn't have PDAC verification, how do I know what code to use for it?

Virtually all product manufacturers suggest potentially applicable code(s) for non-PDAC-verified devices. But remember, manufacturer and third-party suggestions are only that: suggestions. And manufacturers aren't always right (from PDAC's perspective), as the examples below demonstrate.

Sometimes, PDAC voluntarily issues its own guidance that certain manufacturers' coding suggestions are incorrect. In other instances, manufacturers do take products to the PDAC for review but receive verifications that are different from what they suggest (e.g., a manufacturer recommended L5973, L5968, and L5999 for one of its devices; the PDAC ruled in 2013 that only L5999 applied to this product.) 

Ultimately, you remain responsible for what codes you submit in conjunction with your claim. Neither the PDAC nor the MACs consider "the manufacturer told me to do this" a compelling basis for reversing a denied claim.

If a product is not listed on PDAC, can we bill Medicare?

Yes, as long as it is not one of the orthotic codes requiring review. Currently, only L1906, L1845 and all spinal orthoses codes do require review. This means that prior to submitting a claim using one of these codes you should check the PDAC site and confirm the product is listed. 

What does this mean for you? 

When a product doesn't have PDAC verification, you must carefully examine the suggested codes, compare them to the functions and features of the product you're delivering, and make sure you're comfortable that they map directly to the code language in a defensible way.

For additional information see What Does PDAC Approval Really Mean?

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