Below are frequently asked questions regarding PDAC letters (PDAC validation)
Medicare Validation and the PDAC:
Can a manufacturer advertise that Medicare approves a specific product? No
Medicare has a system for validating products for specific HCPCS codes. This is best known as PDAC (Price Data Analysis Contractor) validation.
How is a PDAC validation obtained?
In order to obtain a coding validation letter from the PDAC, the manufacturer must submit the product for a rigorous review. Once successfully completed, the PDAC then issues a validation letter with a list of validated HCPCS codes for that specific DMEPOS. The manufacturer will maintain a copy of that letter for your reference which may also be viewed on the PDAC website at: https://www.dmepdac.com/palmetto/PDAC.nsf/DID/B5UJSK54
What kind of information can I obtain from a validation letter?
A validation letter confirms that the product submitted for review may be billed to the DME MAC with the HCPCS referenced in the PDAC validation letter.
Does a PDAC validation letter infer coverage and reimbursement? No
Having a PDAC validation letter does not guarantee coverage by any payer. Coverage of DMEPOS can be found on your payers (carrier's) website.
Does the PDAC validation letter limit coding to non Medicare carriers (Medicare Advantage Plans, Medicaid, Third Party Payers, ERISA)? No
The PDAC agency has jurisdiction only over Medicare Fee for Service. Other carriers may seek to adhere to the PDAC advisory bulletins. But non-Medicare carriers must specifically state they follow both the Medicare Fee for Service and PDAC guidelines in their DMEPOS policies.
Non Medicare carriers will provide some reimbursement guidelines for AFO's with most inferring they follow the DME MAC policies for coverage. However, it is extremely rare for them to reference any adherence to the PDAC validation letters.
Therefore unless the non Medicare carrier specifically states their adoption of the PDAC validation, the PDAC does not have any jurisdictional authority on non Medicare carriers.
Can manufacturers offer two separate billing recommendations for their products, one for non Medicare patients and the other for non-Medicare (HMO, PPO fee for service) beneficiaries?
In general, one should follow the HCPCS codes noted in the PDAC validation for Medicare Fee for Service Patients; and for non Medicare patients, we have provided a list of recommended codes for our products.
Suggested HCPCS Codes
The responsibility for accurate coding lies with the patient care facility that selects the product, fits the patient, and bills for the service.
The product/device “Supplier” (defined as an O&P practitioner, O&P patient care facility, Podiatrist, Orthopedist, Physical therapist or DME Supplier) assumes full responsibility for accurate billing of Kevin Orthopedic products. It is the Supplier’s responsibility to determine medical necessity; ensure coverage criteria is met; and submit appropriate HCPCS codes, modifiers, and charges for services/products delivered. It is also recommended that Supplier’s contact insurance payer(s) for coding and coverage guidance prior to submitting claims. Kevin Orthopedic Coding Suggestions and Reimbursement Guides are based on reasonable judgment and are not recommended to replace the Supplier’s judgment. These recommendations may be subject to revision based on additional information or alpha-numeric system changes.
PDAC Coding Verifications
The Medicare Pricing Data, Analysis and Coding (PDAC) group conducts coding reviews on durable medical equipment, orthotics, prosthetics and supplies (DEMPOS). The coding verification process is voluntary, except when mandated by Medicare for billing purposes. To see the DEMPOS Product Classification List, visit dmepdac.com.
The assignment of the HCPCS codes in these letters is not an approval or endorsement of the products by Medicare or the PDAC contractor, nor does it imply or guarantee claim reimbursement or coverage. Always refer to the specific Local Coverage Determination (LCD) or Policy Article for correct billing instructions.
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Kevin Orthopedic Team