New Codes Requiring Coding Verification Review from PDAC
In response to the prior authorization updates published last month, which we discussed in ourMay 22 post, the DME MACs issued a new Coding Verification Review requirement for two orthotic HCPCS codes. This article will explain what a CVR is and discuss the recent changes, which will be effective starting December 1, 2024.
What You Need to Know
Coding Verification Reviews are performed by Palmetto GBA, the current Medicare contractor for Pricing, Data Analysis and Coding. DMEPOS manufacturers/distributors are responsible for submitting CVR requests for their devices, which can either be voluntary or mandated by DME MAC policy. The PDAC then reviews the product and determines the appropriate HCPCS code for Medicare billing. Once verified, the PDAC sends a letter back to the manufacturer/distributor (also known as a PDAC Letter) and adds the device information to the Product Classification List, including the approved HCPCS billing code. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.
On June 6, 2024, Noridian and CGS announced a change to their Knee Orthoses and Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Articles. These updates were specific to the "Coding Verification Review" requirements, adding HCPCS codes L1843 and L1951, respectively, with an effective date of December 1, 2024. This was a direct result of the updated prior authorization list because all codes that require prior authorization also require a CVR. L1843 and L1951 were the only newly added orthotic HCPCS codes that did not already require coding verification. The DME MACs state that any products currently published on the PCL with HCPCS code L1843 or L1951 do not need to be reverified.
What this Means for You
For claims with DOS on or after December 1, 2024, any products billed using codes L1843 or L1951 must be on the on the Product Classification List. If you bill for either of these HCPCS codes and the AFO/knee orthosis you deliver was not verified by PDAC, Medicare will deny the claim and you will not receive payment. To help prevent denials, it is important to educate your staff about these new requirements. Starting December 1, you should check the PCL prior to delivery for any product you bill using code L1843 or L1951. If the product is not listed with the appropriate HCPCS code, then a PDAC verified knee orthosis/AFO should be provided instead. Practitioners will also need to include the specific product name and manufacturer in their notes. Without this information, the DME MACs cannot confirm if the delivered knee orthosis/AFO was PDAC verified, which will result in a denial. More information about this update can be found on thePDAC website.