I respectfully disagree with the recent letter
by Josh White (owner of SafeStep). He and other
advertisers are advising that everything is okay
with the AFOs their companies provide to the
podiatry community. Whether that is true or
false is subject to the answers to the questions
I am outlining below.
Q: Is it mandatory that the PDAC verify custom
(and pre-fabricated AFOs)?
A: In a previous letter, I advised that the
answer to #1 is NO with the exception of devices
which meet the criteria for L1906 a pre-
fabricated multi ligamentous ankle support. Only
those devices must receive PDAC verification.
Q: If the PDAC does review and issue
verification for a specific product does that
automatically qualify the device for payment?
A: My previous LTE advised the readers that
based on communication with the PDAC medical
director himself, that PDAC does not issue
payment, coverage or reimbursement directives.
The PDAC may advise the DME MAC’s on payment
issues, but the final regulations concerning
payment, coverage and reimbursement is up to the
DME MAC.
In this case, the LCD covering AFOs is owned by
DME MAC C. As a means to refresh all of our
memories, the PDAC’s main purpose is to identify
whether or not a specific product matches the
HCPCS coding definition, which are stipulated by
the HCPCS Common Work Group. That is a far cry
from ever verifying coverage, reimbursement or
payment for any device.
Since Dr. White and many others are confused,
I’d like to use some parallel scenarios in both
the DME and Part B Medical/Surgical world to
better illustrate the issues here.
In the DME world, most podiatrists provide their
diabetic patients with therapeutic shoes and
inserts. The inserts must be verified. So
assuming you provide a patient with 4 pairs of
inserts, one may say that all four should be
covered. The answer is obviously up to 3 are
covered and one pair is not. Here the PDAC has
issued the HCPCS verification, yet the DME MAC
is stipulating we won’t cover that fourth pair.
A second analogy, would be the diabetic patient
who wants a therapeutic shoe which may have been
PDAC approved (just as an AFO), yet the patient
does not have one of the six qualifying
diagnosis listed in the T. Shoe LCD.
In the Part B world, a patient presents for at
risk (routine) foot care with no at risk class
findings or LOS. You trim the toenails (11719)
and trim the hyperkeratosis (11055). Is this
covered? The procedures certainly match the CPT
definitions, yet the LCD says this is not
covered.
Q: Does the PDAC verification letters provide
proof that these devices meet the LCD height
requirements of the LCD?
A: Most of the PDAC verification letters were
issued prior to the implementation of the
draconian height requirements, stipulated by the
LCD. I have yet to see Dr. White or any of the
advertisers who claim their PDAC verification
automatically qualifies their device for payment
provide any proof that these devices were in
fact verified with the new height requirements.
Q: Does PDAC provide any written guidance on
this controversy?
A: The PDAC has a payment guide which does in
fact provide written proof of the explanations I
have provided. Below you will find some verbiage
which should bring this controversy to a
grinding halt: “The PDAC does not provide
billing advice. They only provide coding advice.
The PDAC receives frequent inquiries regarding a
billable HCPCS code and a payable HCPCS code. One
may think the two are the same; however, this is
not the case. If the HCPCS code is billable to
the DME MAC it does not necessarily mean it is
payable. A billable HCPCS code is one that can
be submitted on a claim to the DME MAC. A
payable HCPCS code is one that will be
considered for payment by the DME MACs only if
the item meets:
1. The definition of Durable Medical Equipment
(DME);
2. Falls under a benefit category, which CMS
defines as the category of the Medicare
program to which an item or service applies.
Examples of benefit categories include
durable medical equipment, physician services,
inpatient hospital services, and diagnostic
tests, and;
3. Is covered under other general DME guidelines.
Specific details can be found on the applicable
DME MAC web site for which you are billing.”
The source document for this is located on the
PDAC website and may be found at:
https://www.dmepdac.com/docs/search/dmecs_guide.p
df 07/18/12”
The obvious conclusion here is that if the DME
MAC LCD precludes coverage for one reason or
another then payment should not be made.
In the simplest of terms, the PDAC medical
director and the PDAC website are the go to
authority. Dr. White and the other advertisers
who claim that PDAC verification automatically
qualifies their devices for payment are clearly
not providing accurate information to the
readers or their clients. I see no grey here
whatsoever.
Q: So where do I as a practitioner go from here?
A: Since the device you are making is custom, be
sure and incorporate the fibular neck into the
cast and mark it on your cast. Be sure and
incorporate this on your order form so the lab
understands you wish to have the uprights
fabricated to the height stipulated by the LCC
(2-4 cms from the fibular head). Be sure and
denote this in your progress notes.
If the device is PDAC approved, not custom
fabricated and falls short of the heights
mandated, then despite PDAC’s approval, the
device would not qualify for reimbursement
I can’t stress this enough, to the advertisers
and readers that PDAC approval by and of itself
does not automatically qualify your AFO billing
for reimbursement.
To summarize for all:
PDAC has made it clear and IN WRITING that it is
NOT THEM who makes reimbursement policy but the
DME MAC!
For advertisers to suggest that PDAC approval is
tantamount to coverage only revs up the
confusion factor.
I hope these explanations will help to motivate
all to work together in a spirit of cooperation
rather than in the current climate of distrust
and competition. Our goal should be to better
educate our colleagues and work together to get
this unscientific LCD overturned.
Paul Kesselman, DPM, Woodside, NY,
drkesselmandpm1@hotmail.com
