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Linda Collins Blogger

PDAC Requirement Reversed: Is it Really a “Win”?

Posted by Linda Collins | August 09, 2012

On July 6, 2012 the four Durable Medical Equipment Medicare Administrative Contractors (MACs) posted a revised Local Coverage Determination (LCD) for Ankle-Foot/Knee-Ankle-Foot Orthoses (Effective Date July 1, 2012). The updated LCD has two items of note:

  1. It removed the requirement for PDAC coding verification for all L1930, L1932, L1940, L1960, L1970 and L1971 products.
  2. It re-stated that coding verification is still required for L1906.

While you could conclude that the removal of the PDAC coding verification requirement constitutes a “win” for the O&P industry, the recent action of MAC Region D suggests otherwise. Specifically, that MAC announced a widespread pre-payment review of claims involving codes L1960 and L1970. (It also included L4360 in the list of codes that would trigger pre-payment reviews.) So at least in that Region, even though manufacturers will not have to submit products claiming those codes for verification, suppliers will end up getting audited on them.

The new LCD language suggests the audits will be looking at the applicable diagnosis code to justify medical necessity of the orthotic, as well as appropriate medical documentation to support the diagnosis and prognosis. According to the CMS Supplier Manual, medical records include physician and prosthetist/orthotist assessment of the patient.

We will continue to monitor what the other MAC Regions do and will keep you apprised accordingly.

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